
Class 2fM Jt2/ 
Book, - / / •£ 



V! 



CopyrightlSl . 



MJ0 



COPYRIGHT DEPOSIT 



PRACTICAL TREATISE 



FRACTURES AND DISLOCATIONS 



BY 



FRANK HASTINGS HAMILTON, A.M., M.D.,LL.D. 



BURGEON TO BELLEVUE HOSPITAL, SEW YORK ; CONSULTING SURGEON TO HOSPITAL FOR RUPTURED AND 

CRIPPLES, TO ST. ELIZABETH HOSPITAL, ETC. J AUTHOR OF A TREATISE OX MILITARY SURGERY 

ASD HYGIENE, A TREATISE ON THE PRINCIPLES AND PRACTICE OF SURGERY, ETC. 



SIXTH AMERICAN EDITION, 
REVISED AND IMPROVED. 

ILLUSTRATED WITH THREE HUNDRED AND FIFTY-TWO WOOD-CUTS. 










PHILADELPHIA: 
HENRY C. LEA'S SON & CO. 

1880. 



<^ 



v> x 






Entered according to Act of Congress, in the year 1880, by 

HENRY C.LEA'S SON & CO,, 

in the Office of the Librarian of Congress. All rights reserved. 



COLLINS, PRINTER 



PREFACE TO THE SIXTH AMERICAN EDITION, 



It is now twenty years since the first edition of this work was pub- 
lished. In the mean time but one serious attempt has been made by any 
writer to supply the profession with a similar treatise. In 1859-1861 
and 1862 Dr. E. Grurlt, Professor of Surgery of the Royal University 
at Berlin, published a work in two volumes entitled " Handbuch der 
Lehre von den Knochenbriichen ;" but the work was never completed. 
As far as published it treats exclusively of fractures, the first volume of 
800 pages being devoted to general considerations, and the second volume 
of 860 pages to the study of special fractures, commencing with the 
spine and closing with the humerus. Fractures of the forearm, hand, 
pelvis, and lower extremities are not considered ; nor is any space de- 
voted to the subject of dislocations, with which the subject of fractures 
is so closely and almost inseparably allied. The work is therefore in- 
complete, and to this moment has not been resumed by its distinguished 
author. This must be to all who have any acquaintance with Dr. Gurlt's 
writings a matter of regret, since he alone, after Malgaigne, has shown 
himself a complete master of the subject. He has supplied many origi- 
nal illustrations of fractures, and his references to published cases and 
opinions is simply enormous, furnishing to the student a complete biblio- 
graphy of those fractures of which he treats and of fractures in general, 
up to the period at which he wrote. 

Malgaigne' s great work was published at two periods, the volume on 
fractures in 1847, and the volume on dislocations in 1855 ; since which 
time no new edition has been published ; but it has continued to be con- 
sidered, very justly, standard authority in all parts of the world where 
surgeons have been the fortunate possessors of this remarkable work. 

Of both of the treatises above named it is proper to say, that, except 
in three or four instances, neither of them furnishes any figures illustrat- 
ing the actual appearance of the limbs in the various forms of fractures 
and dislocations, or of the mechanical appliances to be employed in their 
reduction and support. In a department of surgery having so much in 
common with a purely mechanical art, these omissions constitute serious 



IV PREFACE TO THE SIXTH AMERICAN EDITION. 

defects, inasmuch as without such illustrations the text is sometimes 
unintelligible. They are, however, defects which might have been easily 
remedied in later editions if the authors had seen fit to do so. 

The present work remains therefore the only complete treatise on 
fractures and dislocations in any language, except the treatise of Mal- 
gaigne, which latter has undergone no revision or republication since the 
date of its first edition. The author fully appreciates the responsibility 
which he has assumed under these circumstances ; and while he is con- 
scious of having fallen far short of his own ideal standard, he must be 
permitted to claim for his labors, that they have been performed con- 
scientiously, and to the best of his ability. 

In revising the present edition there has been added a chapter on 
General Prognosis ; the chapter on Fractures of the Patella has been 
entirely re-written, in order that the results of a recent exhaustive study 
of this subject might be given ; and most of the chapters have under- 
gone thorough revision. Several illustrations have been omitted to make 
place for new ones, and a few additions have been made from the Ger- 
man edition published in 1877 at Gottingen. 

The author wishes to express his thanks to Charles H. Goodwin, stu- 
dent of Medicine, for a number of excellent drawings for the new wood- 
cuts ; to Dr. J. H. Girdner, his chief of staff at Bellevue Hospital, for 
valuable assistance ; to his publishers for their uniform courtesy, and for 
their fidelity in the execution of their portion of this work; and finally 
— as a long delayed tribute of affection and gratitude — to one who has 
assisted him in the reading of the proof of each successive edition, but 
who declines to be known to the public except as his Dearest Friend, 
Companion, and Counsellor. 

FRANK H. HAMILTON. 



43 W. 32d Street, New York. 
August 20, 1880. 



PREFACE TO THE FIRST EDITION 



The English language does not at this moment contain a single com- 
plete treatise on Fractures and Dislocations. The two small volumes 
of Desault, and the one of Boyer, issued near the close of the last cen- 
tury, and translated into English early in this, may perhaps properly 
enough have been regarded as complete treatises at the time of their 
publication, but they certainly cannot be so considered now. The 
several chapters on " Diseases and Injuries of the Bones," contained in 
the Lecons Orales of Dupuytren, translated in 1846, and the Treatise 
on Fractures in the Vicinity of the Joints, and on Certain Forms of 
Accidental and Congenital Dislocations, by Robert Smith, are invalu- 
able monographs, but neither of them claims to be anything more than a 
collection of occasional and miscellaneous papers. The writings of 
Amesbury and of Lonsdale relate only to fractures. Even the justly 
celebrated quarto of Sir Astley Cooper is no more than what its title 
plainly declares it to be, A Treatise on Dislocations and on Fractures 
of the Joints; but since the announcement of the present volume, a 
translation of Malgaio-ne's great and crowning work on Fractures and 
Dislocations has been commenced by Dr. Packard, of Philadelphia, and 
the first volume has been placed in the hands of the American profes- 
sion. Should the remaining volume be rendered into English, the gap 
in our literature will be measurably filled. 

Under these circumstances I might scarcely have thought it worth 
while to continue my labors, already so near their completion, had it 
not seemed to me that Malgaigne, whose researches have been truly 
marvellous, had failed in some measure to give a just representation of 
the observations and improvements which have been made from time to 
time by my own countrymen. 

The contributions of American surgeons to this department had to 
be sought chiefly in medical journals, many of which have long been 
discontinued, and most of which were inaccessible to the great French 
writer. Even to an American, the labor of exhumation from archives 
hitherto almost unexplored has not been small ; and it is probable that 



VI PREFACE TO THE FIRST EDITION. 

many valuable papers have been overlooked ; indeed it is impossible that 
it should be otherwise. 

I am free to say, also, that I have been encouraged by a hope that 
my own personal experience, obtained during many years of public and 
private service, might be of some value to my contemporaries. 

Very little space has been devoted to what is now only historical, 
except so far as was necessary to correct certain time-consecrated errors, 
or to confirm and illustrate the practice of the present day ; but by a 
pretty full report of characteristic examples, selected from more than 
one thousand cases already published by. myself, by copious references 
to the examples recorded by others, and by a careful exclusion of what- 
ever has not been confirmed by experience or established by dissection, 
I have endeavored to make this treatise useful both to the student and 
practical man, and a reliable exponent of the present state of our art 
upon those subjects of which it treats. 

In order to render the description of the various forms of apparatus 
employed in the treatment of fractures more intelligible, and to avoid 
the necessity of lengthened explanations, a large number of illustrations 
have been introduced, more, perhaps, than might be thought necessary, 
especially as in several instances the apparel which is figured is not that 
which is recommended by the author. It is believed, however, that by 
a study of the principal forms of approved dressings the reader will be 
better prepared for the exigencies of practice ; and that by the simulta- 
neous presentation of those which are not approved, he will be saved 
from a wasteful expenditure of his time in the contrivance of useless 
apparatus. It is not in the discovery and multiplication of mechanical 
expedients that the surgeon of this day declares his superiority, so much 
as in the skilful and judicious employment of those which are already 
invented. 

The author desires to acknowledge his indebtedness to very many of 
his professional brethren, throughout the United States, for the prompt- 
ness with which they have responded from time to time to his inquiries, 
and for the generosity with which they have opened their pathological 
collections and placed valuable specimens at his disposal. 

He wishes also to express his special obligations to Dr. J. R. Lothrop, 
of this city, who has kindly aided him in revising most of the proof- 
sheets as they have been issued from the press. 

FRANK H. HAMILTON. 

Buffalo, N. Y., December, 1859. 



CONTENTS. 



PART I. 

FKACTUKES. 



CHAPTER I. 

PAGE 

General Division of Fractures 27 

CHAPTER II. 
General Etiology of Fractures 29 

CHAPTER III. 
General Semeiology and Diagnosis of Fractures 33 

CHAPTER IV. 
Repair of Fractures 88 

CHAPTER V. 
General Prognosis of Fractures 44 

CHAPTER VI. 
General Treatment of Fractures 52 

CHAPTER VII. 
Delayed Union, Fibrous Union, and Non-Union of Fractures . . 73 

CHAPTER VIII. 

Bending, Partial Fractures, and Fissures of the Long Bones . . 84 

§ 1. Bending of the Long Bones 84 

§ 2. Partial Fractures of the Long Bones .88 

§ 3. Fissures 96 

CHAPTER IX. 

Fractures of the Nose 10 1 

§ 1. Fractures of the Ossa Nasi 101 

% 2. Fractures and Displacements of the Septum Narium . . . 106 



Vlll CONTENTS. 

CHAPTER X. 

PAGE 

Fractures op the. Malar Bone 109 

CHAPTER XT. 

Fractures op the Upper Maxillary Bones . . . . . . 112 

CHAPTER XII. 
Fractures of the Zygomatic Arch 117 

CHAPTER XIII. 
Fractures op the Lower Jaw .121 

CHAPTER XIV. 
Fractures op the Hyoid Bone . . . 147 

CHAPTER XV. 

Fractures op the Cartilages op the Larynx 152 

§ 1. Fractures of the Thyroid Cartilage . . . . . . . .152 

§ 2. Fractures of the Thyroid and Cricoid Cartilages .... 152 

§ 3. Fractures of the Cricoid Cartilage 154 

CHAPTER XVI. 

Fractures of the Vertebra 156 

§ 1. Fractures of the Spinous Processes 156 

§ 2. Fractures of the Transverse Process . ... . .158 

§ 3. Fractures of the Vertebral Arches 159 

§ 4. Fractures of the Bodies of the Vertebrae 165 

1. Fractures of the Bodies of the Lumbar Vertebrae . . .166 

2. Fractures of the Bodies of the Dorsal Vertebrae . . .168 

3. Fractures of the Bodies of the five lower Cervical Vertebrae . 169 

4. Treatment of Fractures of the Bodies of the Vertebrae . .172 

§ 5. Fractures of the Axis 174 

.§ 6. Fractures of the Atlas 178 

§ 7. Fractures of the first two Cervical Vertebrae (Atlas and Axis) at the 

same time 178 

CHAPTER XVII. 
Fractures of the Sternum .179 

CHAPTER XVIII. 



Fractures of the Rtbs and their Cartilages 186 

§ 1. Fractures of the Ribs 186 

§ 2. Fractures of the Cartilages of the Ribs 191 



CONTENTS. IX 



CHAPTER XIX. 

PAGE 

Fractures of the Clavicle 193 



CHAPTER XX. 

Fractures of the Scapula .... 
§ 1. Fractures of the Body of the Scapula 
§ 2. Fractures of the Neck of the Scapula 
§ 3. Fractures of the Acromion Process . 
§ 4. Fractures of the Coracoid Process . 

CHAPTER XXI. 



220 
220 
225 
226 
230 



Fractures of the Humerus 233 

§ 1. Fractures of the Head and Anatomical Neck 234 

§2. Fractures through the Tubercles . . . . . . 238 

§ 3. Longitudinal Fractures of the Head and Neck, or Splitting off of 

the Greater Tubercle 239 

§ 4. Fractures through the Surgical Neck (including Separations at the 

Upper Epiphysis) 241 

§ 5. Fractures of the Shaft below the Surgical Neck, and above the Base 

of the Condyles 259 

§ 6. Fractures at the Base of the Condyles (including Separations of the 

Lower Epiphysis) 271 

§ 7. Fracture at the Base of the Condyles, complicated with Fracture 



between the Condyles, extending into the Joint 



§ 8. Fractures of the Internal Epicondyle 283 

§ 9. Fracture or Diastasis of the External Epicondyle .... 290 

§ 10. Fractures of the Internal Condyle 291 

§ 11. Fractures of the External Condyle 294 

CHAPTER XXII. 

Fractures of the Radius 298 

CHAPTER XXIII. 

Fractures of the Ulna ' . ■ . 333 

§ 1. Fractures of the Shaft of the Ulna 333 

§ 2. Fractures of the Coronoid Process of the Ulna . . . . 337 

§ 3. Fractures of the Olecranon Process 346 

CHAPTER XXIV. 

Fractures of the Radius and Ulna . . . . - . . . . 354 

CHAPTER XXV. 

Fractures of the Carpal Bones . 366 

CHAPTER XXVI. 
Fractures of the Metacarpal Bones . . . . . . .366 



CONTENTS 



CHAPTER XXVII. 

PAGE 

Fractures of the Fingers 370 

CHAPTER XXVIII. 

Fractures of the Pelvis, and Traumatic Separations at its Sym- 
physes . . i . . . . . . . . 373 

§ 1. Fractures of the Pubes . . . .373 

§ 2. Fractures of the Ischium 377 

§ 3. Fractures of the Ilium . . . . 378 

§4. Fractures of the Acetabulum . 382 

§ 5. Fractures of the Sacrum . . . . . . - . . 389 

§ 6. Fractures of the Coccyx . . . . . . * . . .390 

CHAPTER XXIX. 

Fractures of the Femur 392 

§ 1. Fractures of the Neck of the Femur 393 

(a) Neck of the Femur within the Capsule 394 

(b) Neck of the Femur without the Capsule .... 419 

(c) Neck of the Femur partly within and partly without the Cap- 

sule 427 

§ 2. Fractures through the Trochanter Major and Base of the Neck of 

the Femur 427 

§ 3. Fractures of the Epiphysis of the Trochanter Major . ■ . . 428 

§ 4. Fractures of the Shaft of the Femur 430 

§ 5. Fractures at or near the base of the Condyle 484 

§ 6. Fractures of the Condyles 491 

(«) Fractures of the External Condyle 491 

(b) Fractures of the Internal Condyle 493 

(c) Fractures between the Condyles and across the Base . . 494 

(d) Separation of the Lower Epiphysis 496 

§ 7. Non-union and Delayed Union of Fractures of Shaft of Femur . 497 

CHAPTER XXX. 

Fractures of the Patella 501 

CHAPTER XXXI. 

Fractures of the Tibia 528 

CHAPTER XXXII. 

Fractures of the Fibula '. 533 

CHAPTER XXXIII. 

Fractures of the Tibia and Fibula 538 

CHAPTER XXXIV. 

Fractures of the Tarsal Bones 563 



CONTENTS. XI 



CHAPTER XXXV. 



PAGE 

Fractures of the Metatarsal Bones 567 



CHAPTER XXXVI. 

Fractures op the Phalanges of the Toes 568 

CHAPTER XXXVII. 
Gunshot Fractures 569 



PART II. 

DISLOCATIONS. 

CHAPTER I. 

General Considerations 583 

§ 1. Division and Nomenclature 583 

§ 2. Predisposing Causes 584 

§ 3. Direct or Exciting Causes 585 

§ 4. Symptoms . 585 

§ 5. Pathology .586 

§ 6. Prognosis . . . 588 

§ 7. Treatment 588 

CHAPTER II. 

Dislocations of the Lower Jaw ' . 591 

§ 1. Double or Bilateral Dislocations 591 

§ 2. Single or Unilateral Dislocations 595 

§ 3. Conditions of the Jaw simulating Luxation 596 



CHAPTER III. 



Dislocations of the Spine 

§ 1. Dislocations of the Lumbar Vertebrae 

§ 2. Dislocations of the Dorsal Vertebrae 

§ 3. Dislocations of the Six Lower Cervical Vertebra? 

§ 4. Dislocations of the Atlas 

§ 5. Dislocations of the Head upon the Atlas, or Occipito-Atloidcan Dis- 
locations 612 



598 
599 
600 
603 
610 



Xll CONTENTS 



CHAPTER IV. 

PAGE 

Dislocations of the Ribs 612 

§ 1. Dislocations of the Ribs from the Vertebrae . . , . . . 612 
§ 2. Dislocations of the Ribs from the Sternum . . . .613 
§ 3. Dislocations of one Cartilage upon another 615 

CHAPTER V. 

Dislocations of the Clavicle 615 

§ 1. Sterno-Clavicular . .615 

O) Dislocations Forwards at the Sternal End . .'."'. . 615 

(b) Dislocations of the Sternal End of the Clavicle Upwards . 620 

(c) Dislocations of the Sternal End of the Clavicle Backwards . 621 
§ 2. Acromio-Clavicular ,623 

(a) Dislocations of the Acromial End of the Clavicle Upwards . 623 
(&) Dislocations of the Acromial End of the Clavicle Downwards 629 

(c) Dislocations of the Acromial End of the Clavicle under the 

Coracoid Process . . . . • 630 

(d) Dislocations of the Clavicle at both ends simultaneously . 631 

CHAPTER VI. 

Dislocations of the Shoulder (Scapulo-Humeral) .... 633 
§ 1. Dislocations of the Shoulder Downwards (Subglenoid) . . . 633 
Dislocations, with Fracture of the Humerus near its Upper End . 661 
§ 2. Dislocations of the Humerus Forwards (Subcoracoid and Subcla- 
vicular) 662 

§ 3. Dislocations of the Humerus Backwards (Subspinous) . . . 670 

4 Partial Dislocations of the Humerus 673 

CHAPTER VII. 

Dislocations of the Head of the Radius (Humero-Radial) . . 678 

§ 1. Dislocations of the Head of the Radius Forwards .... 678 

§ 2. Dislocations of the Head of the Radius Backwards . . . 683 

§ 3. Dislocations of the Head of the Radius Outwards . . . 685 

CHAPTER VIII. 

Dislocations of the Upper End of the Ulna Backwards (Humero- 

Ulnar) 686 

CHAPTER IX. 

Dislocations of the Radius and Ulna (Forearm) at the Elbow- Joint 687 

§ 1. Dislocations of the Radius and Ulna Backwards . . . . 687 

§ 2. Dislocations of the Radius and Ulna Outwards (to the Radial Side) 697 

§ 3. Dislocations of the Radius and Ulna Inwards (to the Ulnar Side) . 704 

§ 4. Dislocations of the Radius and Ulna Forwards .... 706 

S; 5. Dislocations of the Radius Forwards and Ulna Backwards . . 708 



CONTEXTS. Xlll 



CHAPTER X. 



Dislocations of the TTeist (Radio-Carpal) 709 

§ 1. Dislocations of the Carpal Bones Backwards 711 

§ 2. Dislocations of the Carpal Bones Forwards 714 

CHAPTER XI. 

Dislocations of the Lower End of the Ulna (Inferior Radio-Ulnar) 716 
§ 1. Dislocations of the Lower End of the Ulna Backwards . . . 716 
§ 2. Dislocations of the Lower End of the Ulna Forwards . . .717 

CHAPTER XII. 

Dislocations of the Carpal Bones (among themselves) . . . 719 

CHAPTER XIII. 

Dislocations of the Metacarpal Bones (at the Carpo-Metacarpal 

Articulations) 721 

CHAPTER XIV. 

Dislocations of the First Phalanges of the Thumb and Fingers 

(Metacarpophalangeal) 725 

§ 1. Dislocations of the First Phalanx of the Thumb Backwards . . 725 

§ 2. Dislocations of the First Phalanx of the Thumb Forwards . . 732 

§ 3. Dislocations of the First Phalanx of the Fingers .... 734 

CHAPTER XY. 

Dislocations of the Second and Third Phalanges of the Thumb 

asd Fingers (Phalangeal) 735 

CHAPTER XVI. 

Dislocations of the Thigh (Coxo-Femoral) 737 

§ 1. Dislocations Upwards and Backwards on the Dorsum Ilii . . 740 
§ 2. Dislocations Upwards and Backwards into the Great Ischiatic 

Notch 766 

§ 3. Dislocations Downwards and Forwards into the Foramen Thy- 

roideum 774 

§ 4. Dislocations Upwards and Forwards upon the Pubes . . . 780 
§ 5. Anomalous Dislocations, or Dislocations which do not properly belong 

to either of the four principal divisions before described . 785 

1. Dislocations directly Upwards 785 

2. Dislocations Downwards and Backwards upon the Posterior 

Part of the Body of the Ischium, between its Tuberosity 
and its Spine 789 

3. Dislocations Downwards and Backwards into the Lesser or 

Lower Ischiatic Xotch 790 

4. Dislocations directly Downwards 791 

5. Dislocations Forwards into the Perineum .... 791 



XIV 



CONTENTS. 



§ 6. Ancient Dislocations of the Femnr . 

§ 7. Partial Dislocations of the Femnr 

§ 8. Coxo-Femoral Dislocations, complicated with Fracture of the Femur 

§ 9. Voluntary or Spontaneous Dislocations of the Femur 



PA(iE 

793 

800 
801 
804 



CHAPTER XVII. 

Dislocations op the Patella 

§ 1. Dislocations of the Patella Outwards 
§ 2. Dislocations of the Patella Inwards 
§ 3. Dislocations of the Patella upon its Axis 
§ 4. Dislocations of the Patella Upwards 



812 
812 
815 
815 
819 



CHAPTER XVIII. 

Dislocations of the Head of the Tibia (Femoro-Tibial) 
§ 1. Dislocations of the Head of the Tibia Backwards 
§ 2. Dislocations of the Head of the Tibia Forwards 
§ 3. Dislocations of the Head of the Tibia Outwards 
§ 4. Dislocations of the Head of the Tibia Inwards 
§ 5. Dislocations of the Head of the Tibia Backwards and Outwar 
§ 6. Internal Derangement of the Knee-Joint 



820 
821 
823 

825 
827 
827 
829 



CHAPTER XIX. 

Dislocations of the Lower End of the Tibia (Tibio-Tarsal) 
§ 1. Dislocations of the Lower End of the Tibia Inwards 
§ 2. Dislocations of the Lower End of the Tibia Outwards 
S 3. Dislocations of the Lower End of the Tibia Forwards 



4. Dislocations of the Lower End of the Tibia Backwards 



831 
831 
836 

837 
841 



CHAPTER XX. 

Dislocations of the Upper End of the Fibula 

§ 1. Dislocations of the Upper End of the Fibula Forwards . 
§ 2. Dislocations of the Upper End of the Fibula Backwards 



842 
842 
843 



CHAPTER XXI. 
Dislocations of the Inferior Peroneo-Tibial Articulation 



844 



CHAPTER XXII. 



Tarsal Luxations 



§ 1. Dislocations of the Astragalus . 

§ 2, Astragalo-Calcaneo-Scaphoid Dislocations 

§ 3. Dislocations of the Calcaneum . 

§ 4. Middle Tarsal Dislocations 

§ 5. Dislocations of the Cuboid Bones 

§ 6. Dislocations of the Scaphoid Bones . 

§ 7. Dislocations of the Cuneiform Bones 



845 
845 
851 
853 
853 
854 
854 
855 



CONTENTS 



XV 



CHAPTER XXIII. 
Dislocations of the Metatarsal Bones . 



PAGE 

. 857 



CHAPTER XXIV. 

Dislocations of the Phalanges of the Toes . 



859 



CHAPTER XXV. 

Compound Dislocations of the Long Bones . 



800 



CHAPTER XXVI. 



Congenital Dislocations 

§ 1. General Observations and History 

§ 2. Etiology 

§ 3. Congenital Dislocations of the Inferior Maxilla 

§ 4. Congenital Dislocations of the Spine .... 

§ 5. Congenital Dislocations of the Pelvic Bones 

§ 6. Congenital Dislocations of the Sternum .... 

§ 7. Congenital Dislocations of the Clavicle . . . 

§ 8. Congenital Dislocations of the Shoulder (Upper End of the Hume 

rus) 

§ 9. Congenital Dislocations of the Radius and Ulna Backwards 

§ 10. Congenital Dislocations of the Head of the Radius . 

§ 11. Congenital Dislocations of the Wrist .... 

| 12. Congenital Dislocations of the Fingers .... 

§ 13. Congenital Dislocations of the Hip 

§ 14. Congenital Dislocations of the Patella .... 

§15. Congenital Dislocations of the Knee 

§ 16. Congenital Dislocations of the Tarsal Bones 

§ 17. Congenital Dislocations of the Toes 



876 
877 
879 
882 
882 
883 
883 

884 
887 
888 
888 
889 
889 
896 
897 
899 
899 



LIST OF ILLUSTRATIONS. 



sepa 



FRACTURES. 

FIG. 

1. Transverse, serrated (denticulated), and oblique fracture, From author's 

collection ........... 

2. Perforating and longitudinal fracture 

3. Impacted extra-capsular fracture of neck of femur — vertical section 

4. Fracture of the humerus of a turkey ; united with fragments widely 

rated. From a specimen in the author's cabinet 

5. Fracture of the shaft of the femur ; united with an oblique callus. F 

specimen in the author's cabinet ...... 

6. Application of the "roller," by circular and reversed turns 

7. Many-tailed bandage ......... 

8. Application of the many-tailed bandage ..... 

9. Bandage of Scultetus 

10. Wood and leather splint 

11. Starch bandage applied for a broken thigh 

12. Seutin's pliers .... ...... 

13. Opening of the apparatus with Seutin's pliers .... 

14. " Apparatus immobile," applied over a compound fracture 

15. Von Brun's plaster-cutter ........ 

16. Clavicle, united by ligamentous bands ..... 

17. Tiemann & Co.'s apparatus for ununited fracture of the femur . 

18. Physick's first case, after 28 years 

19. Dieffenbach's drill for ununited fracture ..... 

20. Brainard's perforator, reduced one-half ..... 

21. Graillard's instrument for ununited fractures .... 

22. Fergusson's case of permanent bending ..... 

23. Partial fracture without restoration of the bone to its natural form 

24. Partial fracture of the clavicle without spontaneous restoration 

nature ; taken three weeks after the accident 

25. Partial fracture, after union is consummated 

26. Fracture of the lower jaw . 

27. Bean's maxillary articulator 

28. Bean's apparatus for broken jaw, applied 

29. Plaster model of jaws .... 

30. Kingsley's apparatus, applied to model 

31. Same applied to patient 

32. Gibson's bandage for a fractured jaw . 

33. Barton's bandage for a fractured jaw . 

34. Four-tailed bandage or sling for the lower jaw 

35. The author's apparatus for a broken jaw 

2 



From 



28 
28 
28 

41 

41 
53 
53 
54 
54 
58 
62 
62 
64 
65 
68 
75 
79 
79 
80 
81 
83 
87 
92 

92 
94 
121 
137 
138 
141 
142 
142 
142 
143 
144 
145 



XVlll LIST OF ILLUSTRATIONS. 

FIR. * PAGE 

36. Fracture of the spinous process . . . .. . . . .157 

37. Fracture of the vertebral arch . 159 

38. Oblique fracture of the body of a vertebra ....... 166 

39. Key's case of fracture of the first lumbar vertebra . . . . . 167 

40. Wire bed . . . . ... ... . . .174 

41. Parker's case of fracture of the odontoid process of the axis . . . 177 

42. Development of sternum . . . 179 

43. Fracture of the ribs, with lateral union . . . . . . . 188 

44. Complete oblique fracture of the clavicle . . . . . .195 

45. Fracture of the clavicle outside of the trapezoid ligament . . . .198 

46. Complete oblique fracture of the clavicle at the outer end of the inner two- 

thirds . . . . - . .199 

47. Comminuted fracture of the clavicle ; united ...... 201 

48. Figure-of-8 bandage, for a fractured clavicle ...... 209 

49. Moore's apparatus for fractured clavicle. Back view . . . . 211 

50. Moore's apparatus for fractured clavicle. Front view .... 212 

51. Sayre's apparatus for fractured clavicle ....... 212 

52. Sayre's apparatus for fractured clavicle . . ... . . . 213 

53. Sayre's apparatus for fractured clavicle ....... 213 

54. Fox's apparatus for fractured clavicle ........ 215 

55. The author's apparatus for fractured clavicle ...... 218 

56. Fracture of angle of the scapula . . 221 

57. Comminuted fracture of the glenoid cavity ....... 225 

58. Fracture of the neck of the scapula . . . . . . . . 225 

59. Scapula with epiphyses .......... 228 

60. Fracture of the coracoid process ......... 231 

61. Fracture at the anatomical neck of the humerus . . . . . . 235 

62. Pope's specimen of supposed fracture at the anatomical neck of the hume- 

rus, and reversion of the head ......... 237 

63. Same 237 

64. Humerus, with epiphyses .......... 242 

65. Upper epiphysis of humerus ......... 245 

66. Upper epiphysis separated . . . . . . . . . 245 

67. Fracture of surgical neck of humerus . . 246 

68. Plan of author's long leather arm splint 257 

69. Long leather splint closed at top, and in shape ...... 257 

70. Short splint . .257 

71. Lonsdale's apparatus for extension, in fractures of the humerus . . 263 

72. Clark's extension in fractures of the humerus ...... 264 

73. Fractures of the humerus at the base of the condyles .... 271 

74. Separation of lower epiphysis ......... 272 

75. Reeve's case of separation of the lower epiphysis of the humerus . . 272 

76. Lange's case of separation of lower epiphysis, and detachment of epicon- 

dyles . . . .272 

77. Rose's arm and forearm splint . . . . . . . . . 277 

78. Welch's arm and forearm splint ......... 277 

79. Bond's elbow splint . . . . . . . .' . . .278 

80. The author's elbow splint 278 

81. Fracture at the base of the condyles of the humerus, and between the con- 

dyles 279 

82. Separation of epiphyseal portion of internal epicondyle of the humerus . 287 



LIST OF ILLUSTRATIONS. XIX 

FIG. PAGE 

83. Fracture of external epicondyle . . . . . ... . 291 

84. Fracture of the internal condyle of the humerus . . . . .292 

85. Fracture of external condyle . . . . . . . .295 

86. Mutter's specimen of fracture of the neck of the radius .... 299 

87. Fracture of head of radius . . . . . . . . 301 

88. Scott's apparatus for fractures of the forearm ...... 303 

89. Fracture of the shaft of the radius . 304 

90. Colles's fracture — radius near its lower end 306 

91. Impacted fracture. Author's collection 310 

92. Comminuted fracture. Author's collection . . . . . . 310 

93. Bigelow's case of comminuted fracture of the lower end of the radius . 310 

94. Transverse fracture of lower end of radius ; caused by forced palmar flexion 314 

95. Transverse fracture of lower end of radius ; caused by forced dorsal flexion 314 

96. Fracture at base of styloid process of radius, and laceration of annular 

ligament ............ 315 

97. Nelaton's splint for fracture of the radius near its lower end . . . 320 

98. Bond's splint for fracture of the lower end of the radius .... 321 

99. Hay's splint for fracture of the lower end of the radius .... 321 

100. E. P. Smith's splint for fracture of the lower end of the radius — front view 321 

101. Same as above — back view . . . . . . . . . 322 

102. Hewit's splint 322 

103. Author's palmar splint ; right arm ........ 326 

104. Author's dorsal splint 326 

105. The author's dressing for a fracture of the radius near its lower end — com- 

plete 327 

106. Radius, with epiphyses .......... 332 

107. Fracture of the shaft of the ulna 334 

108. Fracture of the coronoid process of the ulna ...... 339 

109. Ulna, with epiphyses . . 341 

110. Fracture of the olecranon process at its base ...... 347 

111. Olecranon process united by ligament ....... 349 

112. Sir Astley Cooper's method of dressing a fracture of the olecranon process 351 

113. The author's splint for a fracture of the olecranon process, applied . . 353 

114. Fracture of the radius and ulna in the middle third . . . .355 

115. Fracture of the radius and ulna in the lower third ..... 356 

116. Radius and ulna united with displacement ...... 356 

117. Palmar splint 364 

118. Grutta-percha splint for finger ... . . . . . . . 372 

119. Development of os innominatum ........ 374 

120. Clark's case of comminuted fracture of the pelvis 376 

121. Walker's case of fracture of the acetabulum 388 

122. Development of femur 392 

123. Fracture of the neck of the femur, within the capsule .... 395 

124. Intracapsular fracture, caused by a fall upon the trochanter . . . 396 

125. Impacted fracture of the neck of the femur, within the capsule . . 397 

126. Horizontal section of the neck of the femur . . . . . . 402 

127. Extracapsular fracture, with inversion ....... 402 

128. Vertical section of Mrs. Wakelee's femur, acetabulum, and capsule . . 408 

129. Impacted fracture within the capsule ....... 409 

130. Section of the head and neck of the sound femur of an adult . . . 410 

131. Chronic rheumatic arthritis, in hip-joint . . . . . . .411 



XX LIST OF ILLUSTRATIONS. 

FIG. PAGE 

132. Crosby's specimen of fracture of neck of femur within the capsule — un- 

united 414 

133. Mayo's specimen of fracture of the neck of the femur within the capsule 

— united by ligament . . . . ... . . . . 414 

134. Author's apparatus for fractures of the neck of the femur . . . 415 

135. Gibson's modification of Hagedorn's thigh splints 415 

136. Gibson's modified splint applied ........ 416 

137. Impacted extracapsular fracture ........ 421 

138. Same . . . .421 

139. Same 421 

140. Fracture of the neck of the femur ........ 423 

141. Extracapsular fracture of the neck of the femur — ununited . . . 424 

142. Extracapsular fracture of the neck of the femur — with excess of callus . 424 

143. Extracapsular fracture of the neck of the femur — united with irregular 

callus . . 426 

144. Miller's splint for extracapsular fractures 426 

145. Mr. Aston Key's case 429 

146. Sir Astley Cooper's mode of treating fractures of the trochanter major . 430 

147. Physick's thigh splint 437 

148. Liston's dressing of fractured femur with a straight splint . . . 439 

149. Double-inclined plane formerly employed in Middlesex Hospital, London . 443 

150. Amesbury's double-inclined plane ........ 444 

151. Amesbury's splint applied ......... 444 

152. Boyer's thigh splint applied 444 

153. Nathan R. Smith's suspending apparatus, or double-inclined plane . 445 

154. Nott's double-inclined plane ......... 446 

155. N. R. Smith's anterior splint 446 

156. N. R. Smith's anterior splint, applied . . . . . . 446 

157. Palmer's modification of the anterior splint ...... 447 

158. Hodgen's suspension apparatus ........ 448 

159. Neill's straight thigh splint, for extension and counter-extension . . 449 

160. Flagg's thigh apparatus — employed in the Massachusetts General Hos- 

pital. Pelvic belt and perineal straps 449 

161. Same — foot-piece and screw ......... 449 

162. Same — lateral view of the apparatus, without the belt .... .449 

163. Same — front view, with folded sheets laid across 450 

164. Same — apparatus applied, front view ....... 450 

165. Same — apparatus applied, side view ........ 450 

166. Same — mode of applying adhesive plasters to leg 450 

167. Same — -mode of making extension by adhesive plasters .... 450 

168. Same — perineal band secured with a padlock 451 

169. Gurdon Buck's fracture apparatus ........ 452 

170. Horner's thigh splint 452 

171. Joseph Hartshorne's thigh splint ........ 452 

172. Gilbert's extension in fracture of the thigh . . . . . 453 

173. Gilbert's extension applied to both thighs ...... 453 

174. H. L. Hodge's counter-extension in fracture of the femur .... 454 

175. Lente's thigh splint ........... 455 

176. Burge's apparatus for fracture of the femur ...... 455 

177. Burge's apparatus applied . . . . . . . . . 456 

178. T. W. Simmons's suspension-extension apparatus ..... 456 



LIST OF ILLUSTRATIONS. XXI 

FTft. PAGE 

179. Dr. Gribbes's case, posterior view . . . . . . . . 464 

180. Dr. Gribbes's case, anterior view . . . . . . . . 464 

181. Extension during application of plaster of Paris 467 

182. Extension continued until the plaster is bard . . . . . 467 

183. Badly united fracture of femur, treated without permanent extension . 468 

184. Fracture of femur just below trochanter minor . . . . ■ . . 468 

185. E. Daniels's invalid-bed 474 

186. Crosby's invalid-bed, closed 475 

187. Crosby's invalid-bed, open 475 

188. Standard for extension . . . . 476 

189. Iron upright and weight 477 

190. Foot-piece . 477 

191. Extension-band and foot-piece . . . . . . . . . 478 

192. Extension-band and foot-piece folded ........ 478 

193. Mode of applying adhesive plaster for extension 479 

1-94. Author's dressing for fracture of shaft of femur, complete . . . 480 

195. Author's splint for fracture of femur in a child 482 

196. Author's dressing for fracture of femur in a child — complete . . . 482 

197. Fracture of the shaft of the femur at the base of the condyles . . . 484 

198. Crosby's specimen of fracture of the external condyle of the femur . . 492 

199. Sir Astley Cooper's case of fracture of the external condyle of the femur . 492 

200. Transverse fracture of the patella . . . . . . . . 506 

201. Comminuted fracture of the patella ........ 506 

202. Transverse fracture of the patella — exhibiting the relations of the muscles 

to the fracture ........... 506 

203. Fragments of a broken patella separated by flexion of the knee . . 507 

204. Upper fragment of a broken patella drawn up very much by the action of 

the quadriceps femoris . . . . . . . . . .507 

205. Malgaigne's hooks for fractured patella ....... 516 

206. Dorsey's patella splint .......... 518 

207. Sir Astley Cooper's method for broken patella by circular and parallel tapes 518 

208. Sir Astley Cooper's method by a leather band and counter-strap . . 518 

209. Lonsdale's apparatus for fractured patella ...... 519 

210. Lausdale's apparatus for fractured patella ...... 519 

211. Beach's apparatus . . . . . . . . . . . 519 

212. Beach's apparatus applied . . . . . . . . . . 520 

213. Turner's apparatus ........... 520 

214. Wyeth's apparatus ........... 520 

215. The author's mode of dressing a fractured patella ..... 523 

216. The author's wooden inclined plane for fractures of patella . . . 525 

217. Wood's apparatus ........... 526 

218. Development of tibia ........... 529 

219. Development of fibula . . . . .533 

220. Fracture of the fibula near its lower end . . . . . . .534 

221. Dupuytren's splint incorrectly applied 536 

222. Dupuytren's splint, as originally made and applied by himself . . 537 

223. Compound and comminuted fracture of the leg 539 

224. Plaster-of-Paris dressing for fracture of leg, and suspension . . . 548 

225. Van Wagenen's suspension apparatus ....... 549 

226. G-. Wacherhagen's method . . . 550 

227. Hutchinson's splint for extension in fractures of the leg . . . .551 



XX11 



LIST OF ILLUSTRATIONS. 



FIG. PAGE 

228. Neill's apparatus for fractures of the leg requiring extension and counter- 

extension ............ 552 

229. Neill's apparatus for compound fractures of the leg 552 

230. Gilbert's fracture-box . . . . .553 

231. Crandall's apparatus for fracture of the leg requiring extension and coun- 

ter-extension — side view ......... 553 

232. Same — posterior view of the entire apparatus . . . . . .554 

233. Same — posterior view of the lower section . . . . . . .554 

234. Liston's double-inclined plane, applied to the leg in a case of compound 

fracture . • . . . . . . . . . . . . 555 

235. Bauer's wire splints for the leg ......... 555 

236. Swing box for fractures of the leg . . . . . . - . . 556 

237. Salter's cradle for fractures of the leg . . . . . . 556 

238. John W. Trader's suspension apparatus for compound fractures . . 557 

239. Fracture-box for the leg, with movable sides ...... 557 

240. Wire rack for fracture of the leg 558 

241. Malgaigne's apparatus for certain oblique fractures of the leg . . . 558 

242. Malgaigne's apparatus applied ■ . . . . 559 

243. Apparatus for fracture of the tuberosity of the calcaneum . . . 566 

244. Author's movable canvas for gunshot fractures of thigh . . . .. 573 

245. Author's movable canvas for gunshot fractures of thigh, with extension 

on "horses" 573 

246. Hodgen's apparatus for gunshot fractures of the thigh .... 574 

247. Same .574 

248. Grunshot fracture of thigh — side view . . . . . . 580 

249. Same— front view 580 



DISLOCATIONS. 



250. Clove-hitch 

251. Compound pulleys and ring ...... 

252. Double dislocation of the inferior maxilla .... 

253. Same . 

254. Ayres's case of bilateral dislocation of the fifth cervical vertebr 

255. Dislocation of the sternal end of the clavicle forwards 

256. Sir Astley Cooper's apparatus for dislocated clavicle . 

257. Dislocation of sternal end of clavicle upwards . 

258. Dislocation of the acromial end of the clavicle upwards 

259. Dislocation of acromial end of clavicle upwards and outwards 

260. Mayor's apparatus for dislocated clavicle .... 

261. Dislocation of the shoulder downwards' into the axilla 

262. Same 

263. New socket in an ancient luxation of the shoulder downwards 

264. N. R. Smith's method of reducing a dislocation of the shoulder 

265. La Mothe's method of reducing a dislocation of the shoulder — modifi 

266. Sir Astley Cooper's method, with the heel in the axilla 

267. Sir Astley Cooper's method, with the knee in the axilla . 

268. Iron knob employed by Skey instead of the heel 



589 
590 
593 
594 
609 
617 
619 
621 
625 
625 
628 
635 
636 
642 
647 
648 
649 
650 
650 



LIST OF ILLUSTRATIONS. XX111 

FIG. PAGE 



269. Skey's method in dislocations of the shoulder . 

270, Sir Astley Cooper's method by means of pulleys 



271. Indian puzzle, employed to make extension in dislocations of the shoulder 653 



272. Subcoracoid dislocation of the humerus ...... 

273. Subclavicular dislocation of the humerus 

274. Subcoracoid dislocation of the humerus ...... 

275. Subspinous dislocation of the humerus . . . . ... 

276. Displacement of the long head of the biceps ..... 

277. Dislocation of the head of the radius forwards — anatomical relations 

278. Dislocation of the head of the radius forwards . . . 

279. Dislocation of the head of the radius backwards 

280. Dislocation of the upper end of the ulna backwards .... 

281. Dislocation of the radius and ulna backwards ..... 



282. Sir Astley Cooper's method in dislocation of the radius and ulna backwards 692 

283. Wylie's case of complete outward dislocation of forearm . . . . 698 

284. Same, arm nearly extended . . . . . . . . .699 

285. Most frequent form of incomplete outward dislocation of the forearm . 700 

286. Most frequent form of incomplete inward dislocation of the forearm . . 704 

287. Canton's case — dislocation of the radius and ulna forwards . . . 707 

288. Dislocation of the carpal bones backwards . . . . . . 713 

289. Same 714 

290. Dislocation of the carpal bones forwards — skeleton ..... 715 

291. Dislocation of the carpal bones forwards ....... 715 

292. Dislocation of lower end of ulna forwards . . . . . . .718 

293. Partial backward luxation of metacarpal bone of thumb .... 722 

294. Dislocation of the first phalanx of the thumb backwards .... 725 

295. Clove-hitch 727 

296. Sir Astley Cooper's method of reducing dislocations of the thumb by the 

pulleys. . 728 

297. Levis 's instrument for reduction of the phalanges ..... 731 

298. Same 731 

299. Indian " puzzle" — employed in the reduction of dislocations of small 

joints 732 

300. Backward dislocation of the first phalanx of the index finder — reduction 

by extension '........... 734 

301. Dislocation of the second phalanx backwards 735 

302. Dislocation of the second phalanx forwards . . . . . . 736 

303. Dislocation of the femur upon the dorsum ilii ...... 741 

304. Ilio-femoral ligament ........... 742 

305. Dislocation of the femur upon the dorsum ilii, showing relations of ilio- 

femoral ligament ........... 743 

306. Dislocation of the femur upon the dorsum ilii ...... 744 

307. Everted dorsal dislocation 746 

308. Nathan Smith's method of reduction of a dislocation of the head of the 

femur upon the dorsum ilii, by manipulation 751 

309. Relaxation of the ilio-femoral ligament by flexion ..... 753 

310. Hippocrates's mode of reducing dislocations of the hip by extension . 753 

311. Reduction of a dislocation upon the dorsum ilii by pulleys . . .755 

312. Reduction of a dislocation upon the dorsum ilii by the Spanish windlass 755 

313. Jarvis's adjuster — applied in dislocation of the hip ..... 756 



651 
651 



664 
664 
66Q 
671 
675 
679 
679 
685 
687 
688 



XXIV LIST OF ILLUSTRATIONS. 

FIG. PAGE 

314. Bloxham's dislocation tourniquet — applied for reduction of a dislocation of 

the femur upon pubes 757 

315. Bigelow's tripod for vertical extension 766 

316. Dislocation of the femur upwards and backwards into the great ischiatic 

notch . . . . . .767 

317. Same 767 

318. Internal obturator in its natural position ....... 768 

319. Internal obturator in its new position ....... 769 

320. Dislocation upwards and backwards into the great ischiatic notch — "below 

the tendon," when the patient is recumbent ...... 769 

321. Reduction of a dislocation into the great ischiatic notch, by pulleys . . 773 

322. Relations of the ilio-femoral ligament to thyroid dislocations . . . 775 

323. Dislocation of the femur downwards and forwards into the foramen thyroi- 

deum 775 

324. Reduction of thyroid dislocation by manipulation ..... 777 

325. Sir Astley Cooper's mode of reducing recent luxations of the femur into 

the foramen thyroideum ......... 778 

326. Effect of flexion upon the ilio-femoral ligament in the thyroid dislocation 779 

327. Specimen of dislocation upon the pubes, in St. Thomas's Hospital . . 780 

328. Dislocation upon the pubes below the anterior inferior spine of the ilium 781 

329. Dislocation upwards and forwards upon the pubes 782 

330. Reduction of dislocation upon the pubes by extension .... 784 

331. Supraspinous dislocation 787 

332. Anterior oblique dislocation 788 

333. Mechanism of anterior oblique dislocation ....... 789 

334. Voluntary subluxation upon the dorsum ilii 806 

335. Same 806 

336. Dislocation of the patella outwards ........ 812 

337. Dislocation of the patella inwards . . . . . . . . 815 

338. Dislocation of the head of the tibia backwards ...... 821 

339. Incomplete dislocation of the head of the tibia forwards .... 823 

340. Subluxation of the head of the tibia outwards ...... 826 

341. Subluxation of the head of the tibia inwards ...... 827 

342. Dislocation of the lower end of the tibia inwards 831 

343. Same 833 

344. Reduction of a dislocation of the ankle by pulleys 834 

345. Dislocation of lower end of the tibia outwards ...... 836 

346. Partial dislocation of the tibia forwards, with fractures of malleolus inter- 

nus and fibula — skeleton 838 

347. Partial dislocation of the tibia forwards, with fracture of the malleolus in- 

terims and fibula ........... 838 

348. Dislocation of the lower end of the tibia backwards 841 

349. Same 841 

350. Dislocation of the astragalus outwards — anatomical relations . . . 845 

351. Simple dislocation of the astragalus outwards . . . . . . 846 

352. Compound dislocation of the astragalus inwards . . . . . 846 



PART I 



FRACTURES 



FRACTURES 



CHAPTEE I. 

GENERAL DIVISION OF FRACTURES. 

Fractures are divided into Complete and Incomplete, Simple, Com- 
minuted, Compound, and Complicated. 

A Complete fracture is one in which the line of division completely 
traverses the bone. 

An Incomplete fracture is a partial separation of the bone : under 
which name are included Bending, Partial fractures, Fissures and Punc- 
tured or Perforating fractures, the last of which is almost peculiar to 
gunshot injuries. 

A Simple fracture is one in which the bone is broken at only one point. 
The term has no reference to the question of complications, but in its 
technical meaning, as employed by both English and American surgeons, 
it has reference only to the number of fragments into which the bone is 
broken. It would be more correct, perhaps, to substitute the word 
" single" for " simple," as has been done by Malgaigne and some other 
French writers, but I fear that to American surgeons the substitution 
would be rather a source of confusion than otherwise. 

A Comminuted fracture, called by Malgaigne "multiple," is a frac- 
ture in which the bone is broken at more than one point, and in which, 
consequently, the bone is divided into more than two fragments. It is 
used also in a technical sense, and by no means implies minute division 
or comminution of the fragments. 

A Compound fracture is technically one in which there exists also an 
external wound communicating with the bone at the point of fracture. 
It may be either partial or complete, simple or comminuted, or even com- 
plicated, while at the same time it is also compound. 

Complicated fractures are such as present additional complications, or 
complications for which no other specific term has been invented. Thus, 
the fracture may be complicated with the lesion of an important blood 
vessel or nerve, or with great contusion or laceration of the soft parts, 
with a dislocation, or with fractures of other bones, or even with some 
constitutional fault. 

Fractures are also divided into Transverse, Oblique, and Longitudinal, 
according as the direction of the line of separation is at a right angle 
with the axis of the bone at the point of fracture, or as it deviates more 



28 



GENERAL DIVISION OF FRACTUEES. 



or less from this direction. 



Fig. 1. 







Transverse, ser- 
rated (denticu- 
lated) fracture. 



Oblique fracture. 
From author's 
collection. 



But a fracture is called transverse when it 
does not traverse the bone precisely at a 
right angle ; indeed, we usually apply this 
term whenever the obliquity is only moder- 
ate, or when, in the examination of a limb, 
although we are unable to detect the pre- 
cise line of the fracture, we ascertain that, 
without being impacted or serrated, the ends 
of the bones continue to rest upon each 
other, or, being replaced, do not spontane- 
ously become displaced. 

Longitudinal fractures occur generally in 
connection with oblique or transverse frac- 
tures ; as when the lower end of the femur 
is split vertically into the joint, and the 
shaft of the bone is traversed horizontally 
by a fracture which intercepts the vertical 
or longitudinal fracture. A fracture of a 
condyle, or of any projection from the body 
of the bone, is called longitudinal if the di- 
rection of the line of fracture is parallel, or 
nearly so, to the axis of the shaft. 

A Serrated or Denticulated fracture is 
one in which the opposite surfaces denticu- 
late, the elevations upon one fragment being 
reflected by corresponding depressions upon 
the other. 



Fig. 2. 



Fig. 3. 





Perforating and longitudinal fracture. 



Impacted, extra-capsular fracture of 
neck of femur. — Vertical section. 



Impacted fractures are those in which the fragments are driven into 
each other, the lamellated structure of one fragment penetrating the 
cancellous structure of the other. 



GENERAL ETIOLOGY OF FRACTURES. 29 

Writers also occasionally speak of fractures en rave, en bee de fiu+e, 
en bee de plume, spiroid, cuneate, etc. ; but we do not see the propriety 
of multiplying the divisions and incumbering our nomenclature by these 
fancied resemblances. For all useful purposes, the divisions above given 
are sufficient. 

Epiphyseal separations we shall not hesitate to class with frac- 
tures, and to submit them to the same rules of nomenclature. These 
accidents rarely occur after the twentieth year of life ; since after this 
period, and in the case of some bones at a much earlier period, the 
epiphyses are usually united to the diaphyses by bone. 



CHAPTEE IT. 

GENERAL ETIOLOGY OF FRACTURES. 

The causes of fracture may be considered as predisposing and ex- 
citing. 

Predisposing Causes. — Partial fractures, with bending of the 
bones, are most frequent in infancy and childhood ; but complete frac- 
tures occur most often during manhood ; and if they are again less fre- 
quent in old age, it is because the exciting causes are less operative, 
since the fragility of the bones, as a general rule, increases with age. 
It will be noticed, also, that somewhat in proportion as the bone is more 
brittle, its fracture will be more nearly transverse, so that very old per- 
sons have occasionally what has been not inaptly termed the " pipe-stem 
fracture ;" but we must except from this rule fractures occurring in 
children, which are also sometimes transverse, often denticulated or 
splintered, and but rarely oblique. In all of the intermediate periods 
of life, oblique fractures are by far the most common. Females are 
less liable to fractures than males, except in old age, when the law 
seems, in general, to be reversed. As to the season of the year, it has 
been generally observed by surgical writers that fractures were more 
frequent in winter than in summer, and an explanation has been sought 
for in the greater rigidity of the muscles during the cold weather, and 
the greater liability to falls upon the ice and frozen ground. Some 
have affirmed that the bones themselves were more brittle ; but, aside 
from the improbability of this last explanation, it is a matter of question 
whether fractures are actually more frequent in the winter than in the 
summer. If, on the one hand, the rigidity of the muscles and falls upon 
slippery walks are active causes in the production of fractures in the 
one season ; on the other hand, falls from buildings and accidents from 
a great variety of similar causes are equally active agents in the other. 

Mollities ossium, rickets, cancer, tertiary lues, scrofula, gout, scurvy, 
mercurialization, and, in short, all diseases dependent upon cachexia, 
are believed to more or less predispose to the occurrence of fractures. 
Grurlt thinks, however, there is no evidence that scrofula or gout predis- 



30 GENERAL ETIOLOGY OF FRACTURES. 

poses to fractures, and that syphilis is not a very frequent cause. In- 
flammation of the periosteum, also, or of the bone itself, may predispose 
to fracture. It is said, moreover, that the bones of persons who have 
lain a long time in bed break easily. 

Exciting Causes. — The exciting, determining, or immediate causes 
of fractures are of two kinds : mechanical violence and muscular action. 

Of these two, mechanical or external violence is much the most fre- 
quent cause ; and this violence may operate in two ways : by acting 
directly upon the bone at the point at which it separates, and then we 
say the fracture is " direct," or from " direct violence ;" or by acting 
upon some point remote from the seat of fracture, and then we say the 
fracture is "indirect," or from a "counter-stroke." When a person 
falls from a height, alighting upon his feet, and the leg or thigh is broken, 
the fracture is indirect ; so also if the bone is broken by flexion or tor- 
sion. Even direct pressure upon one side of a long bone in a child may 
produce a partial fracture upon the opposite side, which is properly an 
indirect fracture ; or a direct blow upon the trochanter major may occa- 
sion a counter-fracture through the neck of the femur. 

Fractures from muscular action occur most often in the patella, cal- 
caneum, humerus, femur, tibia, and olecranon process of the ulna. 
These accidents may imply some condition of the bones themselves 
which predispose them to fracture ; but I have seen one example of a 
fracture of the shaft of the femur in a large and perfectly healthy man, 
occasioned by a twist of the leg in rolling tenpins. I have also quite 
often known the tibia to break from natural muscular action in persons 
of uncommon vigor ; and there is reason to believe that the patella 
is broken more often from muscular action than from direct force. 
Fractures sometimes occur in the violent contractions of the muscles 
during convulsions, and where no abnormal condition of the bones could 
be assumed to exist. Parker, of New York, relates a case of fracture 
of the humerus in a negro preacher, which occurred in the act of ges- 
ticulation ; also, a fracture of the clavicle occasioned by striking a dog 
with a whip ; in another case the humerus was broken in attempting to 
throw a peach : but the most singular case of all was a fracture of the 
humerus caused by an effort to extract a tooth. 1 

I have myself seen the clavicle broken in the case of a man who was 
reaching back to lift the top of his carriage ; and another in which the 
humerus was broken in a contest to determine the power of the rotator 
muscles of the forearm. 

Lente has seen both femurs broken in epileptic convulsions, in a child 
twelve years of age. The left femur was broken April 10th, 1859, at 
the junction of the upper with the middle third, and the right femur was 
broken at the same point eight months after, and about six weeks later 
he died. The first fracture united with considerable bowing and shorten- 
ing. The second did not unite at all. He had been subject to epilepsy 
since he was fifteen months old. 2 

Remarkable examples of fragility of the bones have been from time 

1 Parker, New York Journ. Med., July, 1852, p. 95. 

2 Am. Med. Times and Advertiser, July 2], 1860, p. 41. 



GENERAL ETIOLOGY OF FRACTURES. 31 

to time recorded. Gibson relates the case of a young man who at the 
age of nineteen had suffered twenty-four fractures. Arnott speaks of a 
girl who at the age of fourteen had suffered thirty-one fractures ; Es- 
quirol had in his possession the skeleton of a woman in which were found 
traces of more than two hundred fractures ; and we have had, at the 
Charity Hospital, a man set. 53, who had suffered eleven fractures and 
two dislocations, in whose case both the susceptibility to fractures and 
to dislocations appeared to be hereditary. 1 In most of these cases, so 
far as is known, union occurred rapidly. 

Nearly all of the cases of fractures occasioned by muscular contrac- 
tion seen by me were transverse, or nearly so, and most of those occur- 
ring in the long bones have been unattended with shortening, the ends 
of the bones not becoming completely displaced from each other. The 
example of fracture of the shaft of the femur before mentioned, as hav- 
ing been broken in rolling tenpins, was, however, an exception. The 
limb was placed by the surgeon in charge, upon a double inclined plane, 
upon the theory that in this position no shortening was likely to occur. 
The bone shortened, however, to the extent of an inch or more, and in 
this position it has finally united. 

Intra-uterine fractures are not yet fully explained, but it is probable 
that they, like extra-uterine fractures, may be ascribed sometimes to 
external violence, and at other times to simple muscular contraction, 
both perhaps acting upon bones already somewhat predisposed by a 
peculiar constitutional cachexy. 

November 18, 1872, a child was brought to me having a fracture of 
the left clavicle, which had united with considerable deformity, the point 
of fracture being at the junction of the middle and outer thirds. The 
mother said that she fell upon her belly about two weeks before the birth 
of the child, striking upon a tub ; delivery occurred at the full period, 
in the hands of an uneducated female accoucheur. Four weeks later 
(when I was consulted) union was complete. 

Lawrence Proudfoot, of New York, has related a case of compound 
fracture in utero occurring in the practice of Dr. Freeman, which was 
apparently caused by external violence. Mrs. F., set. 38, always having 
enjoyed good health, during the sixth month of gestation, while attempt- 
ing to pass through a very narrow passage, was severely pressed upon 
the abdomen, and immediately experienced a severe pain in that region, 
accompanied with nausea and faintness. The following clay, uterine 
hemorrhage, with pain, commenced ; and these symptoms continued at 
intervals, in a form more or less severe, up to the period of her delivery, 
which occurred at fall time, and was perfectly natural. At birth, the 
right foot of the child, a female, was found to be much distorted, and in 
a condition of valgus with equinus, the outer side of the foot being laid 
against the side of the leg above the external malleolus. The tibia, 
also, of the same limb, near its middle, seemed to have been the seat of 
a compound fracture ; the two ends of the bone having united at an angle 
slightly salient anteriorly, and the skin presenting over the point of 

1 The Physician and Pharmaceutist, Feb. 1870. Report by Armenag Assadoorian, 
House Surgeon. 



32 GENERAL ETIOLOGY OF FRACTURES. 

fracture an old cicatrix. The soft tissues adjacent Avere considerably 
thickened. Seventeen months after birth, when the child was seen by 
Drs. Proudfoot, Van Buren, and Isaacs, the foot, although much im- 
proved by the means employed by Dr. Freeman, was still considerably 
deformed, in consequence of contraction of the tendo Achillis ; on cut- 
ting which, the limb was found to be of the same length with the other. 1 

Dr. Aristide Rodrigue, of Hollidaysburg, Pa., has communicated a 
case of fracture with dislocation, which he ascribes to a similar cause. 
The woman, when about four months with child, fell on her left side, 
striking upon a board, and hurting herself severely. At the full period 
she was delivered of a well-grown male child. Its left humerus was 
found to be dislocated into the axilla, and both the radius and ulna of 
the same limb had been broken through their lower thirds, but were now 
united by bony callus at an angle of about 45°, and slightly overlapped. 
In all other respects the child was perfect. It does not appear that any- 
thing was done to the fracture, and the attempt to reduce the humerus 
was unsuccessful. Four years later Dr. R. saw the lad, and found him 
strong and hearty, the dislocated humerus having grown nearly at the 
same rate with the opposite, but the forearm remained "short and de- 
formed as at birth." The hand was of the same size as the hand of the 
sound limb. 2 

Devergie has given an account of a woman, who, when seven months 
with child, struck her abdomen against the corner of a table. Intense 
pain followed, lasting some time. She went her full period, however, 
and the child was then found to have a fracture of the left clavicle, the 
fragments being overlapped somewhat, and united in this position by a 
firm and large callus. 3 A woman also six months gone met with a similar 
accident, and at the full time she gave birth to a feeble child, having in 
one leg a separation of the shaft of the tibia from its lower epiphysis. 
The end of the shaft was necrosed, and projected through a wound in 
the integument. This child died on the thirteenth day. 4 

Schubert reports the case of a female delivered before her term, of 
twins, one of whom w T as born with a fracture of the left thigh, which had 
occurred in utero; the fractured bone had pierced the flesh, through 
which it projected more than an inch, and it was carious. The mother 
stated that about six weeks before the accouchement, during a movement 
of the foetus, she had heard a noise like that produced by breaking a 
stick, and from that moment she had felt pricking pains in her belly. 5 
It is probable that in this instance the fracture was the result of a mus- 
cular action, although it is possible that it was occasioned by the thigh 
having become entangled between the legs of the twin. Similar cases 
have been recorded by Ploucquet, Kopp, Carus, Sachse, Moffat, and 
Brodhurst. 6 



i Proudfoot; New York Journ. Med., Sept. 1846, p. 199. 

2 Rodrigue, Amer. Journ. Med. Sci., Jan. 1854, p. 272. 

3 Devergie, Rev. Med., 1825. 

4 Malgaigne, from Archiv. Gen. de Mel., t, xvi. p. 288. 

5 Amer. Journ. Med. Sci., May, 1828, p. 223; from Zeitsch. fur Staatsarz. von 
Henke, 7e Erg. Heft., p. 311. Holmes's Surgery, vol. iv. p. 826. 

6 Holmes's Surgery, vol. iv. 827, from Med.-Chir. Trans., vol. xliii. 1860. 



GENERAL SEMEIOLOGY AND DIAGNOSIS. 33 

In many other examples upon record 1 the explanation is plainly enough 
to be sought for in the abnormal or rachitic condition of the bones. 
Monteggia saw, in a newly born infant, twelve united fractures. Chaus- 
sier, who has published a memoir upon this subject, mentions two very 
extraordinary cases, in one of which the child presented forty-three 
fractures, and in the other, one hundred and twelve. 2 I myself was 
permitted to see, on the 29th of June, 1853, with Drs. Hawley and 
White, of Buffalo, an infant only four days old, who was born at the full 
time, of a healthy mother, in whom nearly all of the long bones were 
separated and movable at their epiphyses, the motion being generally 
accompanied with a distinct crepitus. The bones were also much 
enlarged in their circumference ; the bones of the forearm and the femur 
were greatly curved ; the fontanelles unusually open, and the clavicles 
were entirely wanting. The child was of full size, but looked feeble. 
It died in a condition of marasmus six months after birth ; at which time 
some degree of union had taken place at several of the points of sepa- 
ration, the limbs having been supported constantly with pasteboard splints 
and rollers. 

Fractures occurring from violence inflicted upon the child by the ac- 
coucheur, or from contractions of the neck of the womb while the child 
is in transitu, are more common occurrences, and do not require a sepa- 
rate consideration. I shall mention several in connection with the vari- 
ous bones in which they have taken place ; among which, one of the 
most interesting is that published by Jacob II . Yanderveer, of Long- 
Branch, N. J. The mother came to bed on the 18th of January, 1847, 
after a labor of more than twelve hours. It was a foot presentation ; 
the child weighed fourteen pounds, and was perfectly healthy, but one 
of the thighs had suffered a complete fracture, occasioned probably by 
the strong contractions of the cervix uteri. With careful splinting and 
bandaging, the bone was finally, but not without some difficulty, kept in 
position and made to unite, so that at the date of the report one would 
not discover that the bone had been broken, except by close inspection. 3 



CHAPTEE III. 

GENERAL SEMEIOLOGY AND DIAGNOSIS, 

Fractures are liable to be confounded with contusions, and with 
various other local injuries, but most often with dislocations ; and espe- 
cially when the fracture has taken place near one of the articulations is 
the differential diagnosis sometimes rendered exceedingly difficult. It 
is with particular reference, therefore, to the general points of distinc- 
tion between fractures and dislocations, that I now propose to speak. 

1 Lond. Med. Times and Graz., April 7, 1860. New Orleans Med. Journ., Nov. 1860. 

2 Chaussier, Bullet, de la Faculte de Med. de Paris. 1813, p. 301. 

3 Vanderveer, Amer. Journ. Med. Sci., May, 1847, p. 378. 



84 GENERAL SEMEIOLOGY AND DIAGNOSIS. 

The special signs or points of difference which belong to each individual 
case will be considered in their proper places. 

The most important general or common signs of a fracture — and by 
" common" signs I mean those which are common to most fractures — 
are crepitus, mobility, and an inability on the part of the fragments to 
maintain their positions when reduced ; indeed, in many cases, this con- 
stantly recurring displacement is due to the fact that the surgeon is un- 
able to accomplish a complete reduction. While, on the other hand, 
dislocations are almost as uniformly characterized by the absence of 
crepitus, by preternatural immobility, and by the fact that, when re- 
duced, the bones do not usually require support to retain them in place, 
or indeed, we may say, by the fact that they are generally reducible. 

Let us study these phenomena a little more in detail. 

Crepitus, occasioned by the chafing of the broken surfaces upon each 
other, when actually present, is almost positive evidence of the existence 
of a fracture. It is possible, however, to confound the chafing of en- 
gorged tendinous sheaths, or of inflamed joints upon which fibrinous 
effusions have occurred, or of emphysema even, for the true crepitus of 
a fracture ; but to the experienced ear and well-practised touch these 
sensations are seldom a source of error. The one is rough, crackling, 
even clicking sometimes, while the other is more subdued, and imparts 
a more uniform sensation to the hand, and but rarely conveys an actual 
sound, unless the ear is directly applied or the stethoscope is employed. 
It is only when the crepitus is transmitted obscurely through a great 
mass of soft tissues, or sufficient time has elapsed for the ends of the 
fragments to become softened by inflammation and partially covered with 
a plastic material, or when, indeed, a dislocation is actually coincident 
with the fracture, that the surgeon is left in doubt. Occasionally, also, 
the existence of caries or of necrosis, in connection with a dislocation, 
might lead to the supposition of a fracture ; but the history of the case, 
aside from the remaining common signs, and the special symptoms here- 
after to be enumerated, would prevent any possibility of error. In a 
few cases the diagnosis may be facilitated by the application of the ear 
or of the stethoscope, as first recommended by Lisfranc. 1 

It must not be forgotten, moreover, that a fracture at one point may 
transmit the sensation of crepitus distinctly enough, but in such a direc- 
tion, owing to the relations of other bones to the one broken, as to mis- 
lead the surgeon, and induce him to locate the fracture in the wrong 
bone. Several examples of this species of deception I shall hereafter 
have occasion to mention. 

Valuable and important as is crepitus in its relations to differential 
diagnosis, unfortunately it is not always present, and for reasons which 
must be plainly stated. First: we cannot, in a pretty large proportion 
of cases, bring the broken ends again into apposition. Whatever mere 
theorists may say to the contrary, and notwithstanding surgeons up to 
this time have rarely ventured to allude to this subject, the fact is that 
we do not usually "set" broken bones. We do not, even at the first, 
bring them into complete apposition, unless it is as the exception. I 

New England Med. Journ., 1824, p. 220. 



GENERAL SEMETOLOGY AND DIAGNOSIS. 35 

speak of the bones once completely displaced by overlapping, and these 
constitute the majority of examples which come under the surgeon's 
observation. Second : in transverse fractures of the patella, and in 
fractures of the olecranon process of the ulna, of the acromion process 
of the scapula, and in all similar detachments of processes and apophyses, 
the action of the muscles, by displacing the fragments, may prevent 
crepitus from being readily produced. Third : in a few cases, such as 
certain fractures of the neck of the femur, of the neck and head of the 
humerus, in a Colles fracture, etc., the broken ends may be impacted, or 
so driven into each other as to forbid the production of motion and 
crepitus ; or they may be simply denticulated, and the consequences, so 
far as crepitus is concerned, will be the same. 

Finally, in very many incomplete fractures, crepitus does not exist ; 
and even when it is present, the sensation is feeble, or very much modi- 
fied, sometimes giving only a faint and single click. Under the head of 
crepitus we may properly include the sharp crack sometimes felt, or even 
heard, by the patient at the moment of fracture. 

Preternatural mobility, less valuable as a means of diagnosis than 
crepitus, is, nevertheless, more constantly present, being never absent, 
in some degree, in all complete, non-impacted, and non-denticulated 
fractures ; but its presence does not, like crepitus, render the existence 
of a fracture quite certain. Whenever the bony lesion takes place in 
the vicinity of a joint, it may be difficult or impossible to determine 
whether the mobility of the limb is due to motion in the joint or to 
motion at the supposed seat of fracture. While, on the other hand, 
the preternatural immobility so generally observed in dislocations may 
give place to preternatural mobility, as when the ligaments and tendons 
surrounding the joint are extensively torn, or the system itself is labor- 
ing under the shock of the accident, or when from any other cause there 
exists great general prostration. 

As to the third common sign mentioned, namely, that broken bones do 
not generally support themselves, but demand for this purpose, in most 
cases, the interposition of splints, bandages, and even of extending and 
counter-extending forces, its authority rests upon the same evidence as 
does the assertion already made, that bones once separated entirely, can- 
not generally be " set," that is, placed again end to end in such a manner 
as to be made effectually to support each other. It rests upon the evi- 
dence of my own personal experience ; to which I am permitted to add, 
also, the personal experience of Malgaigne, who, with a frankness which 
does him great credit, and which, I am sorry to say, has hitherto found 
few imitators, remarks: "Second. That overlapping is the most stub- 
born of all. Here I will add a disagreeable truth, which classical 
authors have kept too much out of sight, namely, that it is so stubborn 
that in an immense majority of cases the efforts of art are unable to 
overcome it." 1 And it must be observed further, that if we shall often 
find it possible to bring the broken surfaces sufficiently into contact to 
develop crepitus, they may still be unable to maintain themselves in this 
position, owing to the obliquity of the line of fracture. 

1 Malgaigne, Traite des Fractures et des Luxations, Paris ed., t. i. p. 102. 



36 GENERAL SEMEIOLOGY AND DIAGNOSIS. 

The other common signs of fracture may be briefly stated. Pain at 
the seat of fracture ; swelling ; ecchymosis : deformity, produced by 
either an angular, transverse, or rotatory displacement of the fragments, 
and which is quite as often due to the direction and force of the impulse 
which occasioned the fracture as to the action of the muscles ; separation 
of the fragments, as in fractures of the patella and olecranon process ; 
and inability to move the limb, a phenomenon due in part to the breaking 
of the bony lever upon which the muscles acted, and in part to the in- 
tense pain caused by any such attempts. This latter symptom is, how- 
ever, often entirely absent. It is not generally present in impacted frac- 
tures, in serrated and partial fractures, or in many other fractures in 
which the periosteum has not yet completely given way. 

Velpeau was the first, I think, to call attention to the fact that 
patients with broken clavicles could very generally raise the arm above 
the shoulder and even to the head, and I have repeatedly verified the 
observation, notwithstanding the separation of the fragments has been 
complete, and the overlapping considerable. In fractures of the neck 
of the femur and of the tibia it is no uncommon thing for the patient to 
walk some distance after the receipt of the injury. 

As has been previously stated, fractures of long bones, caused by 
muscular action, generally occur near the middle of the shaft, and they 
are usually transverse. Direct fractures are also more nearly transverse 
than indirect fractures, but less so than those caused by muscular action ; 
while those indirect fractures which are caused by a force applied in the 
direction of the axis of the bone are, in general, very oblique. But 
what is of more importance in connection with diagnosis is, that in this 
latter class of cases the fracture usually takes place near the point upon 
which the force of the blow is received. Thus, for example, a fall upon 
the hand generally causes a fracture of the lower end of the radius — a 
Colles fracture — or if both bones break, it is generally below the middle, 
and very seldom indeed in the upper third. A fracture of the shaft of 
the humerus near the condyles is a frequent result of a fall upon the 
elbow. The classical fracture of the clavicle, at the junction of the mid- 
dle and outer thirds, is usually caused by a fall upon the shoulder. A 
fall upon the foot causes a fracture, in most cases, near the lower end of 
the tibia, and the same is true, quite often, of the lower end of the femur. 
Exceptions to the rule above stated are most commonly met with in ad- 
vanced life, when falls upon the elbow occasion fractures at the surgical 
neck of the humerus, and falls upon the shoulder sometimes cause frac- 
tures near the sternal end of the clavicle. Similar accidents, in old 
people, also sometimes break the tibia near its upper extremity, and the 
femur within its capsule. 

I cannot dismiss this subject without calling attention to the necessity 
of exercising care and gentleness as well as skill in the examination of 
broken limbs. 

Nothing, in my opinion, betrays a lack of judgment as well as of com- 
mon humanity, on the part of the surgeon, so much as a rude and reck- 
less handling of a limb already pricked and goaded into spasms by the 
sharp points of a broken bone. It is not enough to say that such rough 
manipulation is generally unnecessary, it is positively mischievous ; pro- 



GENERAL SEMEIOLOGY AND DIAGNOSIS. 37 

yoking the muscles to more violent contractions, increasing the displace- 
ment which already exists, and sometimes producing a complete separa- 
tion of the impacted, denticulated, transverse, or partial fractures, which 
can never afterwards be wholly remedied ; augmenting the pain and 
inflammation, and not unfrequently, I have no doubt, determining the 
occurrence of suppuration, gangrene, and death. 

In proceeding to establish the diagnosis in any case, the surgeon 
should sit down quietly and patiently by the sufferer, so as to inspire in 
him from the first a confidence that he is not to be hurt, at least unne- 
cessarily. He ought then to inquire of him minutely as to all the cir- 
cumstances immediately relating to the accident, in order that he may 
determine as nearly as possible its cause, which alone, to the experienced 
surgeon, often affords presumptive, if not conclusive, evidence as to the 
nature and precise point of the injury. From this, he should proceed 
to examine the disabled limb ; removing the clothes with the utmost care 
by cutting them away rather than by pulling ; and when completely ex- 
posed, he should notice with his eye its position, its contour, the points 
of abrasion, discoloration, or of SAvelling ; and not until he has exhausted 
all these sources of information, ought the surgeon to resort to the 
harsher means of touch and manipulation. Nor will his sensations guide 
him to the point of fracture by any other method so accurately as when, 
the patient being composed and his muscles at rest, he moves his fingers 
lightly along the surface of the limb, pressing here and there a little 
more firmly, according as a trifling indentation or elevation may lead 
him to suspect this or that to be the point of fracture. 

The limb, in case of a supposed fracture of a long bone, may now be 
measured with a tape-line, and compared with the opposite limb, having 
first marked with a soft pencil or with ink the several points from which 
the measurements are to be made. 

Finally, if any doubt remains, the limb must be firmly but steadily 
held while the necessary manipulations are performed, for the purpose 
of ascertaining the existence of mobility and of crepitus. Mobility is 
most easily determined by giving to the limb a lateral motion, but, in 
general, crepitus is most effectually developed by gentle rotation. If 
the place of fracture is already pretty well declared by the previous 
examinations, the surgeon should place one finger over the suspected 
point, during this manipulation, by which means the crepitus will be 
more certainly recognized. 

I do not often find it necessary to resort to anaesthetics for the pur- 
pose of insuring quietude and annihilating pain in making these exam- 
inations, since it is seldom that the patient need to be much disturbed : 
but if the examination is not satisfactory, and the diagnosis is important, 
I do not hesitate to render the patient completely insensible, after which 
the questions in doubt may be more thoroughly investigated and per- 
haps definitely settled. 

The surgeon ought not to forget, however, that while the patient is 
under the influence of an anaesthetic, violent manipulations are no less 
liable to rupture bloodvessels, and to lacerate other tissues, than if em- 
ployed when the patient is conscious. Surgeons have not seemed 
always to understand this, and the result has been that in too many 



38 REPAIR OF BROKEN BONES. 

instances they have inflicted serious and irreparable injury ; in one in- 
stance which came under my notice, the injury thus inflicted caused 
tetanus and death. 

It is scarcely necessary to say that the earlier the examination is en- 
tered upon, the more readily will the diagnosis be made out ; and if, 
unfortunately, some time has already elapsed before the patient is seen 
by the surgeon, and much swelling has taken place, the examination is 
still not to be omitted ; and whatever doubts remain we must endeavor 
to remove by repeated examinations, made from day to day, until the 
subsidence of the tumefaction has brought the surfaces of the bone again 
within the reach of our observation. 



CHAPTER IY. 

REPAIR OF BROKEN BONES. 

It is not my intention to enter very fully into a consideration of the 
process of repair in fractures, preferring to leave this subject where it 
more properly belongs, to the general treatises on surgical pathology. 

I only propose to state very briefly a few practical, and I trust I may 
now say, pretty well-established facts, such as the manner or position in 
which this reparative material, whenever it is employed, is applied to 
the broken bones, the length of time which is usually required for the 
completion of the process of repair, and the causes which may impede 
or prevent bony union. 

If I think it necessary to say anything more upon this subject, it will 
be simply to announce my belief that the reparative material, consisting 
originally of a plastic lymph, is poured out from the vessels of the Ha- 
versian canals, the medullary tissue, the periosteum, and more or less 
from all of the lacerated tissues which are immediately adjacent to the 
seat of fracture ; that after a period, longer or shorter, this lymph be- 
comes organized, and begins to receive from the same sources particles 
of bony matter, through which the consolidation is finally effected ; that 
the transition from the original plastic material to bone is in adults 
almost constantly through the interposition of connective-tissue, rarely, 
unless in the case of children, through a cartilaginous tissue, and some- 
times through both consentaneously or consecutively ; that, perhaps, in 
a few fortunate examples bones unite directly or immediately, without 
the intervention of a reparative material ; and finally, that granulation- 
tissue sometimes becomes transformed into bone, in certain cases of com- 
pound fractures, or of fractures in which the process of inflammation ex- 
ceeds certain limits. 

Dupuytren, enlarging upon the doctrines taught by Galen, Duhamel, 
Camper, and Haller, declared that "nature never accomplishes the im- 
mediate union of a fracture save by the formation of two successive 
deposits of callus ;" one of which is derived from the periosteum and 



REPAIR OF BROKEN BONES. 39 

from the adjacent tissues, and from the medulla; while the other, derived, 
perhaps, from the broken extremities of the bone itself, is found at a 
later period directly interposed between these surfaces. The material 
or callus derived from the tissues outside of the bone, and which Galen 
compared to a ferrule, but which Mr. Paget calls " ensheathing," together 
with the material derived from the medulla, compared often to a plug, 
and by Mr. Paget named "interior" callus, are by Dupuytren spoken 
of as the "provisional" or temporary callus, by which the fragments are 
supported, and maintained in contact until the permanent callus is formed. 
This temporary splint is completed or has arrived at the condition of 
bone in a spongy form, at periods varying from twenty to sixty clays ; 
but it does not assume the character of compact bone until a period 
varying from fifty clays to six months has elapsed; after which it is 
gradually removed by absorption. The second process, by which the 
ends of the bone are definitively or permanently united, commences 
when the provisional callus has arrived at the stage of spongy bones, 
and is not completed usually within less than eight, ten, or twelve months, 
"when," says Dupuytren, "it acquires a solidity greater than the original 
bone." 

While it is certain that this eminent surgeon and most accurate observer 
has described faithfully the various phenomena which usually accompany 
the repair of bones in those animals which were the subjects of his expe- 
riments, and that his conclusions have a certain degree of application to 
the human species, it is equally certain that he erred in assuming that 
in man simple fractures always unite by this double process ; yet, such 
is the power of authority, these doctrines w^ere accepted from the first 
without hesitation or debate, and for nearly half a century they have 
occupied the minds of surgeons, to the almost complete exclusion of 
every other theory. Mr. Stanley was among the first to question the 
solidity of the doctrines of Dupuytren, but it remained for Mr. Paget to 
fully expose their many fallacies; nor has Malgaigne, although not 
strictly a disciple of Paget, failed to detect certain of these errors. 

I should also do injustice to myself were I not to mention that at the 
very moment when Mr. Paget was making his observations upon the 
specimens in "the large collection of fractures in the museum of the 
University College," I was myself employed in similar researches both 
among cabinet specimens and in the hospitals of this country and of 
Europe ; and that the conclusions to which I had arrived were nearly 
identical with, although the inferences were far from being so complete 
in their detail as those to which this distinguished pathologist was him- 
self brought. 1 I do not, however, wish to make Mr. Paget responsible 
for any of the opinions upon this subject which I shall hereafter express, 
except so far as they may be found to agree w 7 ith his own published 
views. 2 

I think it may now be fairly stated that the repair of bones by the 
double process described by Dupuytren is, in man, only an exception to 

1 Paper on " Provisional Callus," by Frank H. Hamilton. Buffalo Medical Journal, 
Feb. 1853. 

2 Lectures on Surgical Pathology, by James Paget, Phil, ed., 1854, Chapter XL 



40 REPAIR OF BROKEN BONES. 

a very general rule ; and that fractures may unite by either one of the 
following modes: — 

First. Immediately, or in the same manner that the soft tissues some- 
times unite, by the direct reunion of the broken surfaces, and without 
the interposition of any reparative material. This happens probably 
sometimes in the spongy bones, and in the extremities or spongy por- 
tions of the long bones, especially when one portion of bone is driven 
into another and becomes impacted; as, for example, in some extracap- 
sular impacted fractures of the neck of the femur, in certain impacted 
fractures of the head or neck of the humerus, of the lower end of the 
radius, etc. 

Second. By interposition of a reparative material between the broken 
ends; as when the fragments remain in exact apposition, but immediate 
union fails. This is especially apt to occur in superficial bones, such as 
the tibia; or upon those sides of the bone which are most superficial. It 
is not an unusual circumstance to find the shaft of the tibia during the 
process of union presenting no exterior callus upon its anterior and inner 
surface, whilst the posterior and outer section of its circumference is 
covered with an abundant deposit. In other cases, however, of fractures 
of the shaft as well as of the epiphyses, the intermediate callus secures 
a prompt union, but no ensheathing callus is ever formed. 

Third. Bones broken and not separated, unite occasionally by the 
process described by Dupuytren, namely, by the formation, first, of an 
ensheathing callus, whilst at the same moment the cylindrical cavity 
becomes closed by a spongy plug, or its canal is merely interrupted by 
a compact septum of bone; and second, by definitive callus deposited 
between the broken ends. It is probable that this happens generally in 
children, or during the periods of the greatest activity in the develop- 
ment of bones ; and it is a common mode of union in the ribs, w T hich 
bones, during the whole progress of the union, are necessarily kept in 
motion. My cabinet furnishes many illustrations of ensheathing callus 
in ribs ; and also a few in fractures of the tibia and fibula. 

Fourth. Under similar circumstances, where no displacement exists, 
the fracture may unite by ensheathing and interior callus alone, no in- 
termediate callus ever being formed between the broken ends; in which 
case it may be probably said that the bone itself has never united, and 
the ensheathing callus, instead of being provisional, is permanent or 
definitive. This was essentially the doctrine of Galen, Haller, and Du- 
hamel before Dupuytren added his " fifth period," or the formation of 
definitive callus ; and by these older surgeons it was held to be of uni- 
versal application, except perhaps in the case of children. To this 
doctrine also Malgaigne has returned; at least to the question, "Is there 
always a definitive callus, or complete union of the fragments?" he has 
made this laconic reply: "Galen admitted its occurrence, but only in 
young subjects; it has been obtained in animals, where there had been 
no displacement. I would willingly believe that such is sometimes the 
case in human adults ; but I must confess I have seen only the instance 
above cited, which might just as well be used to prove the compact ossi- 
fication of the provisional callus." He accepts, therefore, the doctrine 
of Galen as having not merely an occasional application, but as explain- 



REPAIR OF BROKEN BONES. 



41 



ing the process of union in the large majority of cases; and in support 
of this extreme view he finds that the exterior callus, which Dupuytren 
called provisional or temporary, is actually permanent, unless removed 
by the absorption consequent upon pressure. 

To all of which we can only say that an examination of five or six 
specimens in our own cabinet, after having carefully divided them with 
a saw, has furnished only one illustration of union by ensheathing and 
interior callus alone. In each of the other specimens the union was 
completed by definitive or intermediate callus. We cannot, therefore, 



Fig. 4. 



Fig. 5. 




Fracture of the humerus of a turkey ; united with the 
fragments widely separated. From a specimen in the au- 
thor's cabinet. 

avoid the conclusion that Malgaigne has 
been deceived as to the relative frequency 
of these different modes of union, and that 
union without intermediate callus is ex- 
ceptional. 

Fifth. When bones are broken and 
overlap, they may unite by the interposi- 
tion of a callus between the opposing sur- 
faces, that is, by an intermediate callus, 
but which will differ from that described 
as the second method, inasmuch as the 
new material will be deposited upon the 
sides of the fragments and not upon their 
extremities. The limb being kept per- 
fectly at rest, and all other circumstances 
proving favorable, this union may take 
place without any excess or irregularity 
in the deposit. The surfaces will unite 
firmly where they are in actual contact ; 
and smooth and well-formed buttresses 
will fill up all the spaces between the 
bones where they are not in actual con- 
tact, sufficient generally to give the requisite strength to this new bond 
of union. This mode of union will be completed sometimes when the 
two ends of the bones are separated laterally an inch or more from each 
other. I have in my collection the bone of a turkey's thigh (Fig. 4) 
thus united by a transverse bony shaft, although separated more than 
one inch ; and what is less common, I possess also a specimen of the 
adult human thigh (Fig. 5). in which an oblique shaft of solid callus 




Fracture of the shaft of the femur ;• 
united with an oblique callus. From a 
specimen in the author's cabinet. 



42 REPAIR OF BROKEN BONES. 

has, after many months, and while no splints were employed, bound to- 
gether firmly the two opposite extremities of the broken bone. 

Sixth. The fragments being overlapped more or less, and suffering 
unusual disturbance, or the adjacent tissues having been much torn, or 
much blood being effused, so that considerable inflammation is caused, 
the amount of callus will exceed what is necessary for the complete 
union of the bones ; and this redundancy may be deposited around and 
upon the broken ends of the bones, or anywhere in their immediate 
vicinity, in layers, or in masses of irregular shape and size. Even the 
bones which are not broken, but which are near, as in the case of the 
fibula after a fracture of the tibia, may become inflamed, or their cover- 
ings may inflame, and they may also contribute to the general mass of 
bony callus. 

Compound fractures, or rather, we ought to say, fractures accompa- 
nied with granulations and suppuration, obey no uniform law of repair, 
so far as the manner and position of the deposit are concerned ; but they 
come together finally with more or less irregular distributions of ossified 
matter, according to the varying circumstances of imperfect coaptation, 
mobility, etc., in which they may chance to be placed. Occasionally 
the amount of callus is less than occurs in simple fractures, and at other 
times the excess is very great. 

That was, no doubt, a beautiful thought, which ascribed the formation 
of provisional callus to an intelligent efficient cause, which in this man- 
ner sought to support the fragments until a reunion of their divided ends 
was accomplished. But the beauty of a conception supplies no evidence 
of its truth ; and we have grave doubts whether Nature ever allows any 
interference with her laws even in an exigency, unless by the substitu- 
tion of a miracle. Provisional callus is, in our opinion, just as much 
the necessary result of natural laws, as is definitive. It is formed be- 
cause in that condition of the parts and of the general life its formation 
was inevitable. Whether useful for the purposes of repair or not, it 
will, under certain circumstances, exist. In the repair of certain frac- 
tures, provisional callus, it is conceded, seldom occurs. Thus it is with 
the cranium, the acromion, coracoid and olecranon processes, the patella, 
and with all those portions of bones which are immediately invested with 
a synovial capsule. Will it be affirmed that in the examples just named 
this callus is not formed because it is not required ? To us it seems that 
nowhere could it prove more useful, since, with the single exception of 
the cranium, it is in these very cases that the obstacles to a reunion are 
the most serious. In fractures of the patella, olecranon, etc., the action 
of the muscles tends constantly and powerfully to displace the fragments, 
and gladly would the surgeon avail himself of the assistance of a tem- 
porary callus, but it is rarely present, at least in any useful degree. So 
also in fractures of the neck of the femur within the capsule, and in 
other similar cases, we cannot say that temporary callus would not be 
advantageous in facilitating the retention of the fragments, yet the " in- 
telligent efficient agent" neglects to furnish it. 

The only satisfactory reason which, as we think, can be assigned for 
the absence of callus in these cases, is found in the doctrines we now 
advocate ; that is to say, it is usually absent because that amount of 



REPAIR OF BROKEN BONES. 43 

excitement and irritation is usually absent which alone determines its 
formation. In the case of the olecranon, patella, etc., the fragments 
being separated from each other by muscular action, so that no painful 
pinchings or chafings occur, and their rough surfaces or sharp points 
being rather drawn away from than protruded into the flesh, no sufficient 
provocation exists for the production of inflammation and effusion. 
Hence the failure of provisional callus ; but wherever the fracture 
occurs, and however moderate the action, definitive callus does not fail ; 
still the broken surfaces of the patella and olecranon are softened, and 
smoothed, and covered over with a new matter, which, if contact could 
have been secured and preserved, would certainly have served to con- 
solidate and repair the breach. The natural reparative process proceeds, 
but only the accidental process is omitted. This latter, however, is seen 
again even here, when from other and unusual causes a sur-excitement is 
established. 

Temporary callus is not formed upon bones invested with synovial 
membranes, because here, too — as in the neck of the femur — there are 
not so many structures lacerated and irritated, and the supply of this 
effusion must be the less not only in proportion to the less intensity of 
the inflammation, but also to the less amount of structures inplicated. 

Possibly other and more satisfactory reasons may be assigned why 
provisional callus is not formed usually when the neck of the femur is 
broken within the capsule ; but we certainly can never admit the com- 
mon, and, as here applied, the too palpably absurd explanation, that it 
is not wanted. It is wanted, and in no case so much as in the one now 
supposed. 

Provisional callus has, therefore, no final purpose, but it is the un- 
avoidable result of certain abnormal conditions. It still occurs every- 
where when against and in the vicinity of the bone there are the requi- 
site lesion and action, and it will occur as certainly when there is no 
fracture at all, but only a caries, a necrosis, or a simple bony or perios- 
teal inflammation ; and whilst it is doubtless true that in fractures it 
sometimes renders valuable aid to the surgeon, it is equally true that it 
often proves a source of hindrance. 

Dupuytren, in determining the limits of his " third" period, or of that 
in which a provisional callus is formed of sufficient strength to support 
the fragments, has given what has been usually quoted as the natural 
period within which bones may be said to be united, that is, ' ; from the 
twentieth or twenty-fifth day, to the thirtieth, fortieth, or sixtieth." 
But this depends so much upon the age of the patient, his general con- 
dition of health, the condition and position of the broken ends, as well 
as upon the bone itself, and the point at which it is broken, with many 
other circumstances, that it would be unsafe to establish any absolute 
laws in reference to this point. 

In very early infancy, union is accomplished in half the time required 
in adult life, and it is generally thought to be still more retarded in 
advanced age, but Malgaigne has not found this latter observation con- 
firmed by his own experience ; nor have I observed any marked differ- 
ence, in this respect, between persons of middle and old age. 

Various constitutional causes, as we shall hereafter explain more fully, 



44 GENERAL PROGNOSIS. 

retard bony union. Motion, also, sometimes delays consolidation : frag- 
ments which are overlapped do not unite as speedily as those which are 
placed end to end, and other complications interfere in a similar manner, 
such as lesions of nerves, of bloodvessels, comminution of the bone, the 
interposition between the ends of the fragments of a blood-clot, a por- 
tion of muscular, tendinous, or other tissue, etc. In general, the bones 
of the lower extremities, independently of their size, unite more slowly 
than the bones of the upper extremities. 

Epiphyses, when separated, unite by the same process as fractures of 
the bone. It is affirmed, however, that, when certain epiphyses unite 
with much displacement, the shafts from which they have been separated 
cease to grow, and the limbs become atrophied. 

For a more complete consideration of the causes which retard the 
union of bones, I beg to refer the reader to the chapter on " Delayed 
Union, and Non-Union of Bones." 



CHAPTER Y. 

GENERAL PROGNOSIS. 

The prognosis in fractures must vary greatly according to the place, 
character, and complications of the accident; and for this reason it is 
impossible to give anything beyond a few general maxims at this time, 
leaving the more precise and detailed statements until we come to con- 
sider each individual fracture. 

We have already, in the preceding chapter, considered some of the 
points of prognosis, especially those relating to the average time in which 
bones unite, the causes of delayed union, and of non-union, etc. 

In general it may be said that simple, oblique fractures occurring in 
the shafts of Ions; bones unite with some shortening. Indeed this rule 
presents but few exceptions. This is due to the overlapping or to the 
impaction, both of which we are in most cases unable to completely over- 
come. It is scarcely necessary to say that the inevitable result of 
such overlapping is a more or less manifest irregularity, or deformity at 
the seat of fracture. In general, however, the natural line of the axis 
of the limb may be preserved. 

Simple transverse fractures of the shafts of long bones, which are of 
rare occurrence, when completely displaced and made to slide past each 
other, are seldom effectually replaced, and are, like oblique fractures of 
the same class, apt to result in shortening and some deformity. 

All compound, comminuted, and complicated fractures, which in their 
very nature present additional obstacles in the way of complete adjust- 
ment and of proper support, are likely to entail deformity. Contrary, 
however, to what is generally supposed, certain compound fractures of 
the shaft of the femur, caused by thrusting a sharp fragment through 
the flesh and skin, if promptly reduced, unite as speedily and with as 
little deformity as simple fractures. 



GENERAL PROGNOSIS. 45 

Gunshot fractures, which are necessarily in most cases compound and 
comminuted, are in a much less degree amenable to treatment with ad- 
justing and supporting apparatus than are most other fractures, and they 
necessarily entail greater deformity, both in the matter of shortening 
and lateral deviation. A certain proportion of these, as well as. of other 
compound and comminuted and complicated fractures, demand, for the 
purpose of obtaining the best possible results, a course of treatment 
having in view the control of the inflammatory action as the primary 
consideration, and the relief of the deformity by lateral supports and 
by extension as the secondary consideration ; although perhaps in most 
cases both are to be regarded as necessary indications of treatment. 
We do not of course include in this statement those cases which demand 
immediate amputation. 

Simple, green-stick fractures, denticulated fractures, and most trans- 
verse fractures do not become displaced in the direction of the axes of 
the bones in which they occur, and may generally be made to unite 
without shortening or deformity. They unite also very speedily. 

Fractures occurring in infancy and childhood unite more quickly than 
fractures occurring in adult life ; more speedily in the robust than in the 
feeble ; and there are certain special conditions, as we have already 
stated in the chapter on delayed union, which tend to retard bony union. 

Fractures of the upper extremities unite in general more speedily than 
fractures of the lower extremities. The smaller bones unite more rapidly 
than the larger bones. In the case of the bones of the face and jaws, and 
of the clavicle, union is especially rapid. This is probably true also of 
the ribs ; and this notwithstanding the fact that in the case of most of these 
bones we encounter peculiar and often insurmountable difficulty in se- 
curing absolute quiet during the treatment. 

Fractures at or near the extremities of certain long bones are less 
liable to displacement, and therefore unite with less shortening and de- 
formity than most fractures of the shaft. They unite also more quickly. 
This is true especially of fractures of the surgical neck of the humerus, 
when the fragments remain in place, of fractures of the lower end of the 
radius, of extracapsular fractures of the neck of the femur, of fractures 
of the lower end of the femur and of the upper end of the tibia. But 
some of these fractures are liable to be complicated with injuries to the 
joints, and to either endanger life or entail a partial or permanent anchy- 
losis. Anchylosis is less liable to result, however, in fractures of the neck 
of the humerus, and in extracapsular fractures of the neck of the femur, 
than in fractures of the lower end of the femur, of the lower end of the 
tibia, and of the lower end of the humerus and of the radius. 

Fractures which actually involve the joints are in general much more 
dangerous to life than other fractures. This statement, however, does 
not include intracapsular fractures of the neck of the femur, and is most 
especially applicable to fractures involving the knee-joint. If old people 
pretty often die not long after receiving intracapsular fractures of the 
neck of the femur, the death is seldom due to the fracture, but rather to 
the shock received and the prolonged confinement and recumbency which 
is perhaps necessitated. In this last-named fracture, the union, if it 
takes place at all, is almost invariably fibrous, and the limb usually short- 
ens very much. 



46 GENERAL PROGNOSIS. 

When the patella, or the acromion process, or the olecranon process, 
is broken, the bond of union is generally fibrous, but if the bond is 
short this does not materially affect the future usefulness of the limb. 
In the case of the patella, when the fracture is caused by muscular action, 
as it generally is, and it is a simple transverse fracture, the new bond of 
union is almost invariably fibrous. 

Anchylosis, more or less complete, is the result of nearly all fractures. 
This may be temporary or permanent. 

Temporary anchylosis is due, first, to disuse and atrophy of the muscles, 
and to passive contraction of the ligaments about the joints. Second, to 
inflammatory effusions and adhesions among the muscular fibres ; between 
adjacent tendons and in the sheaths of tendons ; in the capsules of the 
joints and among the ligaments. 

All of the forms of anchylosis above described may, but do not 
often, become permanent. Usually the products of inflammation are re- 
moved by the natural action of the absorbents in the course of a few 
months, and especially when the natural efforts are aided by friction, 
passive or active motion, or by other appropriate means. Passive con- 
traction of ligaments and atrophy of muscles are never overcome except 
by motion, either passive or active. If they are not overcome in some 
degree within a year, they are likely to be permanent, or to require for 
their relief active surgical interference, such as brisement force, or some 
of the graver surgical operations. 

Permanent anchylosis, sometimes the result of what ought to have 
been only temporary anchylosis, is more often due to the presence of 
cicatricial tissue resulting from lesions of the muscles, to actual lesions 
of tendons or of ligaments, to firm intracapsular adhesions, and finally 
to bony deposits in or about the joints, to bony consolidation of the ad- 
jacent bones, to malposition of fragments, to encroachment of fragments 
upon the joints, and to hypertrophy of fragments. 

Pain, tenderness, and more or less loss of strength in the limbs, lasting 
for months or years, are common as sequelae of these accidents ; but 
which phenomena have in general little or no direct relation to the 
previous existence of a fracture, unless they are present as the natural 
results of the deformity which remains. They are quite as likely to be 
entailed upon severe injuries where no fracture has occurred. 

Having thus briefly stated the general prognosis in fractures, it seems 
necessary to call attention to certain statements recently made by a 
gentleman who enjoys a reputation, and who occupies a position as a 
public teacher of surgery in one of our most flourishing medical colleges, 
and which statements are widely at variance with my own views as 
above given, and with the published views of all other surgeons who 
have given sufficient attention to the subject to entitle their opinions to 
respect. 

Dr. Sayre, of this city, in a Report on Fractures made to the Ameri- 
can Medical Association in 1874, l says : — 

1 Report on Fractures, by Louis A. Sayre, M.D., Prof, of Orthopaedic and Clinical 
Surgery, Bellevue Hospital Med. Col., Surgeon to Bellevue Hospital, etc. Transac- 
tions Amer. Med. Assoc, 1874, p. 301 et seq. 



GENERAL PROGNOSIS. 47 

" Fractures of the long bones require that extension and counter-ex- 
tension, under the influence of chloroform, or other anaesthetic, if neces- 
sary, should be made in a proper direction, until perfect accuracy of 
adjustment is obtained, and, after this, retention and fixation in this 
normal condition until consolidation. [The Italics are Dr. Say re's.] 

" By accuracy of adjustment, I mean the perfectly normal condition 
of the bone as to length and position. When the extension and counter- 
extension have been properly made, the muscles and other tissues sur- 
rounding the bones will necessarily and positively force the fractured 
extremities into their natural position, as above described, unless some 
foreign body, as a shred of muscle or connective tissue, has got between 
the fragments." 

Dr. Sayre closes his remarks, which are comprised in less than four 
pages, by presenting, as a "supplement," a "Table of the Fractures 
treated in Belle vue Hospital in the year 1873, which has been com- 
piled from the hospital wards by Dr. Van Wagenen, late House Surgeon 
to Bellevue Hospital" (actually from April 1, 1872, to April 1, 1873). 

The table referred to, however, does not comprise all of the cases 
treated in Bellevue during that year, but only those treated with the 
plaster-of-Paris dressing, and of this class only those which Dr. Van 
Wagenen found " thoroughly" recorded, so at least the author informs us. 

There is no danger, perhaps, that such extraordinary statements will 
affect the opinions of experienced surgeons in any part of the world, 
but they will be read probably by many inexperienced surgeons, and 
may with them have the weight of authority ; and, indeed, they have 
already been quoted by the author of a treatise on Civil Malpractice, 
intended as a guide to jurists, and which is widely read by lawyers and 
medical men. 1 The author has, however, modified the force of the 
authority by expressing his belief that, while such results might be 
possible with Dr. Sayre, they can hardly be expected from the "ordi- 
nary" surgeon ; but how will it be with Dr. Sayre's peers, nearly all of 
whom, in every part of the world, and w T ith the same appliances used 
by him, declare their inability to make all long bones unite without 
shortening ; and who, indeed, affirm that with them union without some 
shortening is the exception, and not the rule, a doctrine against which 
Dr. Sayre entered his earnest protest both at Detroit and Buffalo. 

Our personal interests, as well as the interests of science and humanity, 
demand that we shall know positively whether shortening can always be 
avoided, or even made the exception rather than the rule ; but we need 
something more than mere assertion, however notorious may be the 
author's reputation for accuracy of observation and for truthfulness of 
statement. 

Having myself, with the assistance of my staff, very thoroughly 
searched the records of Bellevue Hospital from time to time, I am 
prepared to say that the evidence we need is not to be found there ; nor 
has it been supplied in such cases treated by my distinguished colleague 
as have come under my personal observation, yet, having for a number 

1 Civil Malpractice, a Treatise on Surgical Jurisprudence, etc., by Mile- A. McClel- 
land, M.D. New York, Hurd & Houghton, 1877. 



48 GENERAL PROGNOSIS. 

of years served alternately in the same wards at Bellevue with himself, 
my opportunities of observing the results of his practice have not been 
few. That I have not generally adopted his practice, also, will be 
accepted, I trust, as evidence that I did not consider his results satis- 
factory, and that although my declared ability to perform was much 
below his. 

So far as we know, the only proof ever offered is found in the tables 
which Dr. Sayre presented as a supplement to his brief paper, showing 
the results in certain cases at Bellevue by the plaster- of-Paris treatment, 
which is known to be at present Dr. Sayre's favorite method. Pre- 
sumably a portion of them are his own, although it is not so stated. At 
any rate, they all had the benefit of that " skilled assistance" and " the 
mechanical paraphernalia pertaining to a hospital" which Dr. McClelland 
regarded as the necessary condition of Dr. Sayre's remarkable success, 
or of the success which in his belief all surgeons ought to attain. 

Some of the cases, Dr. Van Wagenen informs us, were imperfectly 
recorded, and all such were rejected. It will be found, however, on 
examination of the tables, that not a few have been retained in which 
the results are not exactly known. We are not informed that Dr. Sayre 
himself measured any of the limbs, or personally noted the amount of 
resulting deformity. Accepting, however, the testimony as it stands, 
and confining our analysis to simple fractures, we find twenty -two simple 
fractures of the shaft of the femur. Of these only three have united 
without shortening ; the shortening being given in the nineteen cases as 
ranging from one-fourth of an inch to two inches. In one it is one inch 
and an eighth, in one an inch and a quarter, and in a third it is two 
inches. Of those which are not shortened, one was seven years old, one 
was seventeen years old (and in this latter the fragments were never 
displaced, there being observed only crepitus when the patient was 
admitted, without shortening or deformity), the third was in a man 
twenty-three years old. A reference to the tables constructed from my 
own personal experience by other modes of treatment, which will be 
found in the chapter on Fractures of the Femur, will show that these 
results do not compare favorably with my own in the matter of length. 
In one of Dr. Sayre's cases the femur is bowed out somewhat at the seat 
of fracture. In one the fracture did not unite, and no explanation is 
offered of this fact except that the plaster-of-Paris splint became loose. 

Two simple, intracapsular fractures of the neck of the femur are re- 
corded; also two extracapsular, and one trochanteric fracture. These 
are all shortened; the shortening ranging from one-quarter of an inch 
to one inch. 

The remaining fractures of long bones included in these tables are 
fractures of the tibia and fibula, of the humerus, and of the radius and 
ulna. Rejecting the compound, complicated, and comminuted fractures,* 
as belonging to an exceptional class, although Dr. Sayre has not spoken 
of them as exceptional ; and confining our attention only to simple 
fractures, in which it will be admitted the best results ought to be ob- 
tained ; and rejecting all fractures of the forearm and leg in which only 
one bone was broken, and in which shortening is never expected to take 
place ; there remain sixteen simple fractures of both bones of the leg, 



GENERAL PROGNOSIS. 49 

seven simple fractures of the humerus, and two of both bones of the 
forearm. In only one of this whole number (twenty -five cases) is there 
any reference to the question of shortening, and in this one case the 
limb is said to be shortened five-eighths of an inch. Of the remainder 
it is occasionally said that there is no record, or it is incomplete, al- 
though we are informed in the caption of the tables that all such cases 
were rejected. 

What are we to infer from this almost universal omission of the relative 
length of the two limbs in these latter cases ? In the table of fractures 
of the femur it is never omitted: but simple fractures of the humerus, of 
both bones of the forearm and leg are recorded variously as "cured," 
"union and position good," or " union and position perfect"; but that 
these phrases are not used to imply a restoration of the limbs to their 
normal length, is evident from the fact that in certain other complicated 
fractures the " union and position" are said to be " good" or " perfect," 
and they are nevertheless marked as " shortened." 

The truth is, probably, the limbs were never measured. If they 
were, these omissions cannot be excused, inasmuch as they render the 
tables valueless for the purpose for which they were prepared and pre- 
sented to the association. So far as the question of angular deformity 
is concerned, its existence is mentioned sufficiently often to indicate no 
improvement upon the practice of surgeons generally, although, as is well 
known, this species of deformity, especially that which is caused by a 
simple overlapping of the fragments, while the general line of the axis 
of the limb is perfect, is seldom seen very distinctly until a long time 
after the treatment is suspended, and the patient has been dismissed 
from the hospital, and therefore, if it existed, it may not have been 
observed when the records were made. In short, these tables are not 
what they might be thought to be, reliable testimony as to results ; and 
even as they stand they do not in any measure sustain the statements 
made by Dr. Say re, that even simple fractures of the short or long 
bones can always be made to unite without shortening : but, we repeat, 
Dr. Sayre makes no such exceptions, in favor of fractures of the neck 
of the femur, or of comminuted fractures and compound or complicated 
fractures, provided they do not demand amputation, or there is not some 
foreign body interposed between the ends of the fragments. 

Jan. 4, 1875, Henry Balchemeider, yet. 87, was admitted to Ward 
14, Bellevue, with a simple fracture of the left femur near its middle. 
Five hours after the receipt of the injury two of our most experienced 
house surgeons put the patient under ether, and with pulleys made ex- 
tension until, as they declared, the limbs were of the same length. 
They then applied the plaster-of-Paris splint. The patient was on 
crutches in a few days. Five weeks and three days from date of the 
dressing, the man was brought before the class in my surgical clinic at 
Bellevue, in presence of Dr. Sayre and the late Dr. Krakowizer. The 
splints being removed, the limb was found united with a slight outward 
bend at the seat of fracture, and the knee-joint very stiff. On measure- 
ment I found it shortened one inch. Dr. Krakowizer and others made it 
the same, but Dr. Sayre thought it was a " little lengthened." It will 
not be difficult to understand, from the results of measurement in this 



50 GENERAL PROGNOSIS. 

case, that Dr. Sayre would meet with examples of perfect restoration 
of the bone oftener than Dr. Krakowizer or myself. 

In the previous. editions of this book, I have, in connection especially 
with fractures of the femur, alluded to the difficulty of making accurate 
measurements of limbs, so as to determine the amount of shortening ; 
and I have also mentioned the fact that Dr. Cory don La Ford, of 
Brooklyn, N. Y., had demonstrated by measurement upon the skeleton 
that occasionally the malleoli of the leg were of unequal length in the 
opposite limbs. I have now to call attention to the fact that a certain 
amount of asymmetry in all the long bones of the extremities is the rule 
and not the exception. The observations which led to these conclusions 
Avere first made upon the lower extremities by Dr. W. C. Cox, of Phila- 
delphia, while he was a student of the Pennsylvania Hospital. They 
were subsequently confirmed, and the examination then extended to the 
upper extremities, by Dr. Wm. Hunt, of Philadelphia, by Prof. J. S. 
Wight of Brooklyn, by myself and others, Prof. Wight having especially 
studied the whole subject. 1 The conclusions reached by all were nearly 
identical, namely, that throughout the long bones of both extremities 
there existed usually a certain amount of asymmetry in regard to length. 
Ordinarily the difference is inconsiderable, ranging from one-eighth of 
an inch to one-half, but sometimes much exceeding this without having 
been noticed by the patient or by his friends. In the case of the lower 
extremities the left is more often the longer than the right. 

These conclusions by no means render the measurements of limbs 
valueless, although they place a serious obstacle in the way of our attain- 
ing that precision which is desirable when we seek to determine the 
relative value of different plans of treatment in preventing shortening. 
Unfortunately, I may say, we have not yet devised a method of exten- 
sion so effective that our ignorance of the original normal differences 
causes any embarrassment. The fact is, and always has been, that 
measurement of the limb in which a long adult bone has been broken 
obliquely and has united, shows, in a large majority of cases, that it is 
shorter than the other ; and the frequency of this occurrence is evidence 
that in many cases it becomes the shortest limb, although it was origin- 
ally the longest, and it leaves a possible question whether those few cases 
which we have regarded as perfect results, because the opposite limbs 
were after consolidation of the same length, were not then symmetrical 
solely in consequence of the shortening ; and we may consider it proba- 
ble that in other cases the actual shortening is much more than is indi- 
cated by the measurements. Nevertheless the unpleasant fact remains, 
and is rendered only the more conspicuous, that oblique fractures of 
the long bones in the adult generally shorten, inasmuch as we find in 
nearly all cases the broken limb the shortest. When we have found 
an apparatus or a mode of dressing which will make a broken limb as 
long as or longer than the other as often as it is found to be normally, 
then we may lay aside the tape and line, for it will be of no further use ; 
practically, also, our labors will be ended, for shortenings no greater 

1 Philadelphia Med. Times, Jan. lfj, 1875. Amer. Jour. Med. Sci., April, 1875. 
Archives of Clinical Surgery, Feb. 1877- Hospital Gazette, April 12, 1879. 



GENERAL PROGNOSIS. 51 

than normal deviations occasion no maiming or halting, and are of no 
consequence. 

A distinguished English surgeon has recently said that he has given 
up measuring broken thighs, — because of the uncertainty of measurements, 
I infer. This is a return to the practice of surgeons for many centuries 
preceding the present century. Until within the last thirty years no 
systematic attempt was ever made to determine the exact lengths of limbs 
after fractures. Tables were given from various hospitals at home and 
abroad, declaring how many were cured, with some slight notices of 
deformity, but with no reference to the amount of shortening. It was 
this which led Mr. Johnson, the famous editor of the London Medico- 
Chirurgical Review, to say of Mr. Radley's results, that he would " like 
to know something about the length of the cured limb, and a few other 
matters of that sort." 

In the April number of the Buffalo Medical Journal for 1849, 1 pub- 
lished the results of a careful measurement of 136 cases of fracture of 
the long bones, treated in various ways by different surgeons. So far 
as I know this was the first publication of the kind ever made. In 1853, 
Dr. John Boardman published from my notes additional cases, making 
461 in all. In my report on deformities made to the American Medical 
Association in 1855-6-7, additional cases were reported at length, 
making a total of 605. 

The results of these observations were startling, both to the author 
and the public generally, and led, I have reason to believe, to that wide- 
spread interest which has since manifested itself in this country, as to 
the causes of the apparent defects in this department of surgery, and to 
serious inquiry as to the remedy. Surgeons everywhere were stimu- 
lated to a new exercise of their ingenuity and skill. Then followed 
speedily the abandonment of all the double inclined planes for fractures of 
the femur, and also of the long splints of Desault, Boyer, Liston, Hage- 
dorn, Gibson, Physic, and others, which, while they gave better results so 
far as the form of the limb was concerned, made little or no improvement 
in the matter of length. I do not hesitate to say that within these last thirty 
years, through the more intelligent efforts and correctly applied genius 
of surgeons, the proper treatment of fractures has made more progress 
than it had in all the centuries preceding ; and especially is this true 
of fractures of the femur, where the defects were most apparent and the 
remedies were most needed. 

Shall we cease these efforts now, when the attainment of practical per- 
fection is almost within sight ? So far as the lower extremities are con- 
cerned, with the present appliances, lateral displacement, or deformity 
from this cause, is, in my personal experience, no longer possible, or it 
is scarcely possible ; while the average length of the limbs is greatly 
increased. We shall have abandoned the further advancement of this 
branch of science when we cease to measure limbs. 

As to the mode of measuring limbs I shall speak in connection with 
particular fractures. 



52 GENERAL TREATMENT OF FRACTURES. 



CHAPTEE VI. 

GENERAL TREATMENT OF FRACTURES. 

All that has been said in relation to the propriety of handling a 
broken limb gently, when the surgeon is examining the position and 
character of the fracture, is equally applicable to the lifting and trans- 
porting of the patient to his bed, to the removal of the clothing, and to 
the general management of the limb before it is dressed. Rude or 
awkward manipulations, by which needless pain is inflicted, are not 
simply acts of wanton cruelty, but they are sources, and I think I may 
say frequent sources, of inflammation, suppuration, and gangrene. Here, 
as in all the subsequent handlings, everything should be done slowly, 
thoughtfully, and systematically. Yet it is difficult to state the precise 
manner in which the surgeon ought to proceed. Much will depend upon 
the circumstances of the case, something upon one's natural tact, and 
upon the amount of experience, but more, I think, upon natural kind- 
ness of heart, and social education. The man of refinement and sensi- 
bility will know instinctively how to proceed, and needs no instruction. 
They who lack these qualities can never learn, and it would be quite 
useless to undertake to teach them. I sincerely wish such men as these 
latter would find some more suitable employment than the practice of a 
humane art. 

Nearly all fractures present three principal indications of treatment, 
namely : to restore the fragments to place as completely as possible ; to 
maintain them in place ; and to prevent or to control inflammation, spasms, 
and other accidents. 

It ought to be regarded as a rule, liable only to rare exceptions, that 
broken bones should be restored to place, or to the position in which 
we hope to maintain them, as soon as possible after the occurrence of 
the accident. If the patient is seen within the first few hours, or before 
much swelling has taken place, we scarcely know the circumstances which 
would warrant an omission to adjust the fragments either end to end or 
side by side, as the one or the other might be found to be practicable. 
We have before sufficiently explained the general impossibility of again 
restoring to place, end to end, and fibre to fibre, fragments which have 
been made to override. We are therefore in no danger of being under- 
stood to say that bones should in all cases be immediately " set," in the 
popular sense of this term. They ought to be " set," no doubt, if this 
can be accomplished through the application of a prudent amount of 
force ; but if they cannot be thus placed end to end, they may at least 
be laid in such a manner side by side as to restore, in some measure, 
the natural axi3 of the limb, and prevent the points of the bone from 
pressing unnecessarily into the flesh. 



GENERAL TREATMENT OF FRACTURES 



53 



Experience has, indeed, furnished us with four or five very good rea- 
sons why broken bones should be reduced as soon as possible. When 
the injury is recent, the muscles offer less resistance ; their resistance 
being increased after a time not only by the reaction which ensues upon 
the shock, but also by actual adhesion between their fibres ; effusions 
distend both the muscles and the skin, and compel the limb to shorten ; 
the constant goading of the flesh by the sharp points of the broken bones 
increases the muscular contractions ; the patient will submit readily to 
manipulation and extension at first, but after the lapse of a few days it 
is very seldom Uiat he will permit the limb to be in any manner dis- 
turbed, even if he is assured that his refusal entails upon him a great 
deformity. If it is true that no callus or bony structure is deposited 
earlier than the seventh or tenth day, it is also true that the renewed 
attempt to adjust the bones at this period, by chafing and tearing again 
the tissues, reduces the fracture, in some degree, to the same condition 
in which it was at first, and, consequently, the time which has elapsed, 
or, at least, a portion of it, may be regarded as lost. 

We cannot, therefore, understand the argument by which Bromfield, 
South, and a few other surgeons have persuaded themselves, that reduc- 



FlG. 6. 



Fig. 7. 




iiin 


— 




^~3 


m«*\. 


-Ml!/ 


{%> 


__ l% jy 


I L^S. 




WJ 


& 


nidify 


IjjT 




maim- 




Many 


-tailed bandage. 



tion should never be attempted be- 
fore the third or fourth day ; nor, 
indeed, do we fully appreciate the 
refinement which Malgaigne has 
given to this question, in itself so 
simple. To affirm that we ought 
not to reduce the bones to their 
original positions during the period 
of intense inflammation, or of great 
swelling, or while the muscles are 
acting spasmodically, is only to 
affirm that we may not do what 
is impossible : and the attempt to 
do which, therefore, can only be 
mischievous ; but to authorize their restoration to a better position, by 
such manipulation, extension, and lateral support as they may comfort- 
ably bear, is warrantable under any circumstances. The practice is not 



Application of the "roller" by circular and 
reversed turns. 



54 



GENERAL TREATMENT OF FRACTURES. 



only defensible, but imperative, and we do not think any really sound 
and practical surgeon ever intended to teach the contrary. We say still, 
if bones can be easily reduced, or the position of the fragments improved 
at any moment, or under any circumstances, it ought to be done ; and if 
we fail in accomplishing all that we wish to do in the first instance, we 
must remain incessantly watchful to seize the earliest opportunity which 
presents, to complete the adjustment. No doubt our efforts will prove 
fruitless very much in proportion to the amount of swelling, inflamma- 
tion, or muscular spasm which exists, and also in proportion to the time 
which has elapsed ; but this will not excuse us for omitting to do all 
which the circumstances permit. 

It has been the practice of most surgeons, for a long period, to cover 
the broken limb with some form of a bandage or roller before applying 
the lateral splints. (This observation was more true when I published 
my first edition than it is now.) 

Of these primary dressings there are two principal varieties : first, 
the " roller" or simple bandage, applied to the limb in circular and re- 
versed turns ; and, second, the " many-tailed bandage," consisting of a 
piece of muslin, or other cloth, torn down from each side into a suitable 
number of strips, leaving the centre, which is to be applied to the back 
of the limb, entire. 



Fig. 8. 



Fig. 





Application of the many-tailed bandage. 



Bandage of Scultetus. 



A modification of this latter bandage consists of a number of separate 
strips, so laid upon one another, commencing from above, that each 
strip shall overlap the other by one-third or one-half of its breadth. 



GENERAL TREATMENT OF FRACTURES. 55 

This is called the bandage of Scultetus, and it possesses one advantage 
over the many-tailed bandage just described, especially in the case of 
compound fractures, in the facility with which each separate piece may 
be removed and another substituted. Some surgeons prefer to form the 
bandage of separate strips, and having overlaid them in the manner 
directed, to unite them again into one by running a thread through the 
whole mass along the centre. 

Whichever of these several varieties of strips are employed, the mode 
of applying them is the same. They are folded alternately around the 
limb, being made to overlap and cross upon each other in front, and only 
the last strip or two is fastened with a pin. 

The object proposed in the use of the roller or of the many-tailed 
bandage is twofold : first, to compress and support the muscles, by which 
their tendency to contraction is in some measure controlled ; and second, 
to protect the limb against the direct pressure of the side splints. 

A moment's consideration will convince us that the first of these 
objects is in most cases fully attained by the lateral splints themselves, 
and by the bandages by which they are retained in place ; and that the 
second can be as well accomplished by a single fold of cloth, or by the 
compresses, which ought generally, even when the roller is used, to un- 
derlie the splints. Nevertheless, we should hardly feel authorized to 
reject these primary dressings solely because the splints and compresses 
furnish a convenient substitute, especially since we are compelled to 
admit that they are occasionally useful, unless objections of a more 
serious nature could be brought against them. Unfortunately this latter 
supposition is actually true. By ligating the limb completely, leaving 
no point of the tegumentary surface to which the pressure is not applied, 
they too often occasbn congestion, inflammation, and gangrene. It is 
not until lately that fee attention of surgeons has been sufficiently called 
to this subject ; but the records of surgery are to-day filled with these 
terrible accidents, formerly attributed to the original injury or to the 
splints themselves, but now understood to be plainly traceable to the too 
common employment of the primary bandage. The roller is by far the 
most dangerous dressing of the two, since it does not yield to the swell- 
ing so readily as the bandage of strips, and it is more objectionable also 
on account of the inconvenience of applying and removing it ; but even 
the bandage of strips may be so confined as to produce the same conse- 
quences, as I have myself seen in more than one instance. It is also all 
the more dangerous in the hands of the inexperienced surgeon, because 
he feels a confidence that it will not cause ligation. 

Except in rare cases and for especial reasons, which we shall attempt 
to indicate in their appropriate places, we cannot recommend the employ- 
ment of any kind of bandages next to the skin. 

In order to fulfil the second indication, namely, to maintain the frag- 
ments in place, we employ usually what are called short, side, or coap- 
tation splints, and long or extending splints, or the weight and pulley. 

Side-splints may be constructed from various materials, according to 
the size and circumstances of the limb, or according to the convenience 
of the surgeon ; and as the surgeon cannot be expected to have always 
on hand, at the bedside of the patient, such splints as he might prefer to 



56 GENERAL TREATMENT OF FRACTURES. 

use, it is well for him to understand how to avail himself of such mate- 
rials as may be within his reach, in order that he may make the most of 
his sometimes imperfect resources. 

Lead, sheet-iron, zinc, and other metals have been occasionally em- 
ployed, but especially tin and copper, which possess all of the requisite 
firmness and malleability to allow them to be hammered, and thus 
moulded to the limb. In general, however, they are unnecessarily 
heavy, and demand too much labor to be wrought into shape. I have 
sometimes employed tin splints perforated with large fenestra to dimin- 
ish their weight and increase their flexibility, and found them to answer 
an excellent purpose. The light perforated zinc splints, introduced into 
the U. S. Army during the civil war of 1861-65, by the Sanitary Com- 
mission, were found exceedingly useful. 

Iron-wire splints, made from wire-cloth or coarse gauze, were first 
publicly mentioned, so far as I can learn, in a communication to the 
Meinphis Medical Recorder, made by Dr. J. C. Nott, of Mobile ; but 
they have been brought more particularly into notice, and their construc- 
tion perfected, by Louis Bauer. 1 These splints are moulded upon 
"gypsum or wooden casts," of different sizes, and surrounded with a 
stout iron wire frame, in order to give them the requisite degree of firm- 
ness, and to preserve their forms ; after which they are tinned by gal- 
vanism, and varnished, to prevent them from becoming rusted. When 
applied, Dr. Bauer recommends that they shall be filled with loose cotton, 
and that they shall be held in place by rollers. It is claimed for these 
splints that they are light, flexible, permeable to air and to the perspira- 
tion, and that they permit the application of cooling lotions without 
impairing their firmness ; the last of which is a quality of questionable 
value, since lotions applied to permanent dressings^!' any kind are only 
warm fomentations, and do not, therefore, in this rUpect serve the pur- 
pose for which they are intended. They render the skin tender, and 
disposed to vesicate, and they, also, give rise to a sensation of scalding, 
which is sometimes almost intolerable. The water soaks into the bed, 
and in many other ways renders the patients uncomfortable. Lotions 
are only applicable where the dressings are open, loose, and temporary. 

The same objections hold, also, to this as to all other forms of moulded 
metallic, or carved wooden splints, namely, that they seldom exactly fit 
the limb, even when the supply of assorted sizes is complete, and that 
they are not sufficiently flexible to adapt themselves to anything but the 
slightest irregularity of surface. They are not, however, without merit, 
and they deserve at least a qualified commendation in many cases. 

Horn and whalebone may be employed in thin plates, or in the form 
of narrow strips quilted into cloth ; but they are expensive, and possess 
no special value except in an emergency. Reeds, the coarse rank grass 
which grows in swamps, flags, willow branches, and unbroken wheat 
straw, may be quilted between two thicknesses of cloth in the same 
manner, and form very excellent temporary splints. 1 have especially 
found it convenient to use wheat straw in the form of junks. Gathering 
up a bundle of unbroken straws of the size of my arm, I roll them 

1 Nott and Bauer, Buf. Med. Journ., vol. xii. April, 1857. 



GENERAL TREATMENT OF FRACTURES. 57 

snugly in a broad piece of cotton cloth, cut off the projecting ends, and 
then stitch up the cloth neatly. We have thus a splint of considerable 
firmness, and one which is cool and especially adapted to the summer, 
allowing the perspiration to evaporate freely. Straw splints were em- 
ployed sometimes by Ambroise Part), by J. L. Petit, Larrey, and I have 
seen them in the wards of certain European hospitals, although I am 
unable now to say under whose direction. Mr. Tuifnell, of Dublin, has 
especially recommended them in the form of junks. 1 

Wooden splints, made of pine, willow, white or linden wood, or of 
some other light and easily wrought timber, are probably of more general 
application, and possess greater intrinsic value than splints constructed 
from any other solid material ; but I wish at once, and for all, to dis- 
claim any intention of giving even a qualified approval of any of those 
carved, polished, and generally patented wooden splints, which are man- 
ufactured and sold by clever mechanics, and which one may see sus- 
pended in almost every doctor's office, whether in the city or in the 
country. Constructed with grooves and ridges, and variously inclined 
planes, for the avowed purpose of meeting a multitude of indications, 
such as to protect a condyle, to press between parallel bones, to follow 
the subsidence of a muscular swelling, etc. They never meet exactly a 
single one of these indications, whilst they seldom fail to defeat some 
other indication of equal importance. They deceive especially the in- 
experienced surgeon into the belief that he has in the splint itself a pro- 
vision for all these wants, and consequently lead him to neglect those 
useful precautions which he would otherwise have adopted. 

If carved wooden splints are employed, they ought to be made espe- 
cially for the case under treatment. But this requires time and some 
more mechanical skill than can always be commanded ; and when accu- 
rately fitted, it is quite probable that the subsidence or increase of the 
swelling will, within the next forty-eight hours, render some change in 
the form of the splint necessary, or compel the surgeon to throw it aside. 

We much prefer to use plain, straight strips of wood, of the requisite 
width and length, which may be cut at any moment from a pine shingle 
or a thin piece of board ; but in order that these splints may adapt 
themselves to the inequalities of the limb, and properly support the frag- 
ments, they ought to be covered with a muslin sack, open at both ends ; 
into which, and on the side of the splint which is to be placed against 
the limb, bran, wool, oakum, curled hair, or cotton batting, may be 
pressed, until it is made to fit accurately. I generally prefer cotton 
batting. Bran is liable to get displaced, and curled hair does not pack 
firmly enough. When the sack is sufficiently filled, the two ends must 
be stitched up. This mode of constructing the splint is simple and easy 
of accomplishment ; the splint can be fitted very accurately ; the pad- 
ding never becomes displaced ; and when the bandages are applied, they 
may be pinned or sewed to the cover in such a way that they shall not 
slide or loosen. 

If pads are employed separate from the splint — and for this purpose, 
also, I generally prefer the cotton batting — they ought to be made and 

1 Tuffnell, New York Journ. Med., March, 1847, p. 264. 



58 



GENERAL TREATMENT OF FRACTURES. 



fitted with the same care, and neatly stitched together at their ends, 
rather than pinned. Cotton batting laid loosely next to the skin, or un- 
derneath the splints at any point, will not keep its place so well as when 
it is inclosed in covers — it is more liable to get into knots, and it has 
altogether a slovenly appearance. The pads may be stitched to the roller, 
and in this way secured effectually in place, but loose cotton is subject 
to no control. 

When I speak of pads, it must not be understood that I intend to 
recommend them for compresses, os for the purpose of pressing frag- 
ments into place. Nothing could be a greater source of mischief in the 
dressing of a broken limb. I have only directed their employment as a 
means of adaptation, and to protect the skin against the direct pressure 
of the splint. 

Dr. Jacobs, of Dublin, says that he has seen an excellent splint made 



from the " fresh bark of a tree, taken off while the sap is rising 
fits admirably," says Dr. Jacobs, " just like pasteboard soaked in water." 1 
Dr. C. C. Jewett, of the 20th Mass. Vols., recommends for the same 
purpose the bark of the liriodendron, or tulip tree. 

Hemlock-tanned, undressed, sole leather, cut into shape and soaked 
a few minutes in water, adapts itself easily to the limb and is sufficiently 
firm. It is especially applicable to fractures of the larger limbs. At 
Bellevue Hospital it has for several years taken the place of almost all 
other materials, for the construction of movable splints. Oak-tanned 
leather is less flexible than the hemlock-tanned, and does not make so 
good a splint. The specimens selected should be of medium thickness. 
Before applying the splint the edges should be bevelled on the inner 
side, and the corners rounded, and a piece of woollen cloth should be 
interposed between the splint and the skin. The leather will become 
hard within twenty-four hours, and at the next dressing it may be re- 
moved, covered with a sack made of woollen or cotton cloth, and replaced. 
Dr. Ap M. Vance, assistant at the Hospital for Ruptured and Cripples, 
New York, prefers what is known as "bridle leather," which is more 
plastic than sole leather, hardens as quickly, and becomes as firm. It can 
be made very hard by substituting hot water for cool in soaking the leather. 
A splint is also occasionally made of thin calfskin, veneered with 
some light timber, such as linden or white wood, the latter being subse- 
quently split into strips of from half an inch to one 
inch in width, so as to combine a certain degree of 
flexibility with the requisite firmness. 

The Turks use, according to Sedillot, in a similar 
manner, the " nervures" of palm, laid upon sheep- 
skin, and fastened with wooden thongs ; 2 and Pack- 
ard mentions that he has seen narrow slips of some 
light wood glued in the same way upon soft pieces of 
buckskin, and then fastened together with two strips 
of buckskin, which were also glued to the splints. 3 
wood and leather splint. Common, unpolished pasteboard, cardboard, or the 




1 Jacobs, New York Journ. Med., March, 1847, p. 265, from Dublin Med. Press. 
* Amer. Journ. Med. Sci., vol. xxiii., Feb. 1839, p. 481. 



Packard's edition of Malgaigne, vol. i. p. 173. 



GENERAL TREATMENT OF FRACTURES. 59 

stout millboard used by bookbinders, constitute invaluable domestic re- 
sorts, since they can generally be found in the house of the patient ; 
and if in no other way, pasteboard may generally be had at the expense 
of some paper box or of the loose cover of some old book. For small 
bones, the thinner sheets afford a sufficient support ; but for large bones 
the thick binder's board is necessary. In preparing the latter for use, 
it ought to be moistened with water ; but if soaked too much it will 
separate and fall into pieces, or lose its firmness when dry, in conse- 
quence of having parted with some of its paste. This splint may be 
applied to the limb without the interposition of anything but a few folds 
of muslin cloth, or a piece of flannel ; or we may use instead a single 
sheet of cotton wadding. It must be bound to the limb by the roller 
while it is moist ; and, as it dries speedily, it forms a smooth, firm, and 
reliable splint. 

Felt, made of wool saturated with gum shellac, and pressed into sheets, 
makes an excellent moulding tablet for splints. This may be obtained 
at any hat manufactory. Until recently, they were manufactured, and 
moulded into a great variety of forms, by Dr. David Ahls, at York, 
Pennsylvania. A similar material in now made and sold by J. Peirce, 
of Bristol, Pa. A much cheaper material, however, and which has 
nearly all the qualities of the real felt, may be made from old pieces of 
broadcloth, or from any similar closely woven texture, by saturating it 
thoroughly with gum shellac, the gum being dissolved in alcohol in the 
proportion of one pound of the former to two quarts of the latter. Thus 
prepared, it is to be spread upon both surfaces of the cloth with a com- 
mon paint-brush. When this first coat is well dried by suspending the 
cloth where the air will have free access to both surfaces, a second must 
be spread upon one of the surfaces ; and then a third ; the cloth being 
allowed to dry after each successive coat. Finally, the sheet is to be 
folded upon itself, so as to bring the most thickly covered surfaces to- 
gether, and pressed with a hot flatiron. If it is necessary to have 
greater strength, more gum may be laid upon the cloth, and it may be 
again folded and pressed. When used, it is to be dipped into boiling 
water or held near the fire until it becomes flexible. Shellac cloth 
hardens very rapidly in cooling, and demands, therefore some quickness 
in its application ; but once applied and fitted, it forms a hard but smooth 
splint, well adapted for all the purposes for which it is designed. It is 
well to mention, if one wishes to keep any portion of the solution which 
is not used, that, in order to prevent evaporation, the vessel in which it 
is contained must be closely covered. Boiling water deprives it of a 
portion of its shellac, and it is better to soften it by holding it to the 
fire. Recently, I have found an article, made by I. M. Holly, a manu- 
facturer of hatters' goods, at 77 Greene Street, New York, which is 
better for general use than woollen cloth treated with £um shellac. The 
fabric is lighter, cheaper, and more flexible. It is made of from four to 
six layers of cotton cloth, saturated with gum shellac and smoothly 
pressed. It is sold by the manufacturer at the rate of about two dollars 
per yard. There has been lately introduced from Boston, Mass., a kind 
of blanket cloth, coated on one side only with shellac, but it seems un- 
necessarily thick and heavy, and has not much firmness, and is, I think. 



60 GENERAL TREATMENT OF FRACTURES. 

in all respects much inferior to the cotton cloth shellac material last de- 
scribed. 

The principal objection to all of those forms of splints which contain 
gum shellac is, they harden so rapidly after being made flexible by ex- 
posure to heat, that it is often found difficult to give them an accurate 
mould to the limb. 

It has been objected to the felt splint occasionally, that it is imper- 
vious to air and moisture, and that it confines the insensible perspiration; 
but, as I never use splints of any kind without underlaying them with 
compresses, or woollen cloth, which act sufficiently as absorbents, I have 
never been aware of any inconvenience from this source. 

Dr. R. 0. Cowling, of Louisville, Ky., has called attention to the 
value of Manilla paper in the construction of splints. 1 A limited use 
of this material satisfies me that it possesses most of the qualities of a 
good splint. It is cut into strips, stiffened with starch, and applied 
longitudinally or spirally, as may be necessary to cover the limb com- 
pletely and smoothly. For the lower extremities six to eight layers are 
required. The material may be obtained at most large paper stores. 

The employment of gutta-percha as a coaptation splint was first sug- 
gested and practised by Oxley, of Singapore. For fractures of the 
thigh, and for the large bones generally, I prefer a thickness of about 
one-sixth or one-fifth of an inch ; but for the fingers or toes it need 
not be more than one-sixteenth of an inch in thickness. In its natural 
state, and at the ordinary temperature of the body, it is nearly as hard 
and as inflexible as bone ; but when immersed in hot water it almost im- 
mediately softens, and would become too soft to be conveniently handled 
unless soon removed. It can therefore be adapted to any surface, how- 
ever irregular, and its form may be changed as often as may be neces- 
sary. It does not harden as rapidly as felt, and it possesses, therefore, 
in this respect, an advantage, since it allows the surgeon more time for 
adjustment; w 7 hile, on the other hand, it hardens much more rapidly 
than either starch, paste, or dextrin. Ten or twenty minutes is all the 
time usually required for gutta percha to acquire that degree of firmness 
which will prevent it from yielding under the pressure of a bandage. 

To use gutta percha skilfully requires some experience, and I have 
known surgeons to reject it after a single trial ; but by those who have 
acquired the necessary skill it is generally regarded as an invaluable 
resource. 

When constructing from this material a thigh-splint, we should order 
a very large tin pan, or some open, flat tray, in which we may lay the 
splint at full length. If the splint is required to be twelve inches long 
and six inches wide, we must cut it about fourteen inches long by seven 
wide, so as to allow for the contraction which alwa3 T s takes place more 
or less when the hot water is applied. It is then to be laid upon a 
sheet of cotton cloth of more than twice the width of the splint, in order 
that the cloth may envelop it completely when it is folded upon it ; and 
the cloth should be enough longer than the splint to enable us to handle and 
lift it by the two ends without immersing our fingers in the hot water. 

1 American Practitioner, Jan. 1871. 



GENERAL TREATMENT OF FRACTURES. 61 

Beside, if the gum is not thus covered and supported, it will adhere to 
the vessel, to the fingers, to the surface of the limb, and indeed to what- 
ever else it comes in contact with ; it may even fall to pieces, or become 
very much stretched and distorted by its own weight. The cloth cover 
will generally adhere to the splint, and may be permitted to remain upon 
it permanently. 

Place the splint, thus covered, in the basin, and pour on the water 
slowly. As soon as it is sufficiently softened, lay it over the limb, 
moulding it carefully with the hands, or by pressing it against the limb 
with a pillow. If it does not harden rapidly enough, this process may 
be hastened by sponging the outer surface with cold water ; and as soon 
as it has acquired sufficient firmness to support itself, it may be removed 
and immersed in a pail of cold water or placed under a hydrant ; after 
this, it is to be neatly trimmed and wiped dry, when it is ready for use. 

When gutta percha remains a long time exposed to the air, it gradu- 
ally oxidizes, its color becomes darker, it loses its tenacity and flexi- 
bility. This may be prevented by keeping it constantly immersed in 
cold water. It may be sufficient to place it in a damp cellar. 

The same objection has been made to gutta percha which is occasion- 
ally made to felt, namely, that it confines the perspiration, but to this 
we have already sufficiently replied. 

There is scarcely any fracture demanding the use of a splint in which 
I have not demonstrated its utility, but it is especially valuable, as I 
shall have occasion to mention again, as an interdental splint in frac- 
tures of the jaw, and as a moulding tablet in all fractures occurring in 
the vicinity of joints. 

Sheets of gutta percha of any required thickness may be obtained in 
this city of Mr, Bishop, the manufacturer, on Twenty-fifth Street near 
the East River. One pound will make about four thigh splints. 

Benjamin Welch, of Lakeville, Conn., has contrived a very ingenious 
application of gutta percha to the purposes of a splint, by veneering a 
thin plate of the gum with equally thin plates of elastic wood. The 
veneering is laid upon both sides, and then it is pressed into form in 
moulds. The elasticity of the wood, together with the plasticity of the 
gum, enables the surgeon to change its form somewhat at pleasure, by 
dipping it into hot water. Its form cannot, however, be changed to any 
great extent, and by frequent immersion in hot water the veneering is 
apt to loosen from the gutta percha. 

The moulding tablet of Albert Smee, composed of gum Arabic and 
whiting, spread upon cloth, 1 has nothing special to recommend it ; any 
more than the cloth splints, hardened with the whites of eggs and flour, 
used by Larrey. 2 Starch and alum, glue, pitch, and various other ma- 
terials of a similar character deserve only to be mentioned as having 
been occasionally employed, but which have never succeeded in securing 
for themselves the confidence of surgeons. 

1 Amer. Journ. Med. ScL, vol. xxvi. p. 220, May, 1840 ; from London Lancet, 
Jan. 25, 1840. 

2 Amer. Journ. Med. ScL, vol. ii. p. 216, May, 1828; from Journal des Progres, 
vol. iv. 



62 



GENERAL TREATMENT OF FRACTURES 



Fig. 11. 



Immovable or Permanent Dressings. — In 1834, Setitin, of Brussels, 
introduced the use of starch as a means of hardening the bandages ; 
his method of using which is essentially as follows : A dry roller is first 

applied to the skin, and then smeared with 
starch ; all of the bony prominences and 
irregularities of the limb are filled up or 
covered with cotton batting, charpie, down, 
etc. ; strips of pasteboard, or of binders' 
board moistened and covered also with 
starch, are now laid alongside the limb, 
over which again are turned in succession 
one, two, or three layers of the starched 
roller ; the number of rollers and the 
thickness of the pasteboard being propor- 
tioned to the size of the limb or to the 
required strength of the splint. The 
whole is completed by starching the out- 
side of the last bandage. 

This dressing will generally become 
dry within from thirty to forty hours ; 
which process may be expedited by ex- 
posing its sides as much as possible to 
the air, or by the application of artificial 
heat with bags of dry sand, or with hot 
bricks. As a temporary support until 
the drying is completed, some surgeons 
lay upon each side of the limb additional 
splints, securing them in place with tapes. 
As soon as the bandages are dry, they 
are to be cut along the front to a sufficient 
extent to permit of an examination of the 
limb, and then closed with an additional roller. For the purpose of 
opening the bandages, both at this period and subsequently, Seutin uses 
a pair of strong scissors or pliers, such as are represented in Fig. 12. 




Starch bandages, applied for a broken 
thigh. 



Fig. 12. 




Seutin's pliers. 



On the third or fourth day, or as soon as the subsidence of the swell- 
ing may render it necessary, the bandages should be cut open through 
their whole extent, the edges pared off and brought together again 
snugly with an additional roller. 

In 1837, Velpeau substituted dextrin (" British gum") ; a kind of glue 
or jelly obtained by the continued action of diluted sulphuric acid upon 



GENERAL TREATMENT OF FRACTURES. 63 

starch at the boiling-point. It is prepared for use by dissolving it in 
alcohol or tincture of camphor, or camphorated brandy, until it has ac- 
quired about the consistence of honey ; at this point hot water should 
be added, reducing its consistence to that of thin treacle, when, after one 
or two minutes' shaking, it is ready for application. According to F. 
D' Arcet, the proportions most favorable to the drying and solidifying of 
the apparatus are, one hundred parts of dextrin, sixty of camphorated 
brandy, and fifty of water. Malgaigne, to whom I am indebted for this 
observation of D' Arcet, says, also, in a note, "As regards dextrin, an 
important point was recently brought practically under my notice, viz., 
that, as sold in the shops, it is often unfit for making an agglutinative 
mixture ; it forms lumps with alcohol, as starch does with cold water, 
without cohering ; and twice in succession I have been obliged to change 
the supply at the Hopital Saint Antoine. The dextrin thus deteriorated 
is whiter and less saccharine ; it crepitates more in the fingers ; and on 
pouring a few drops of tincture of iodine into the solution, there is pro- 
duced a violet tint, indicating the presence of fecula ; while true dex- 
trin, treated with iodine, gives a vinous red, or the color of onion-peel." 
The addition of one part of common glue to six of dextrin, renders the 
splint more tough. 

Velpeau soaked his bandages with the dextrin before applying them, 
but, like Seutin, he applied his first roller dry. He used but one band- 
age, which he carried first from below upwards, and then from above 
downwards ; and he rarely thought it necessary to employ the pasteboard 
as a collateral support. 

A mixture composed of equal parts of precipitated chalk and gum- 
arabic, reduced to a proper consistence by boiling water, applied to 
rollers while they are being applied to the limb, forms a firm and light 
splint. It has the advantage also of hardening quickly. 

Startin and Tait, of London, recommend paraffin, which, being thor- 
oughly melted, is cooled a little, to render it more viscid, and then rubbed 
into the meshes of the bandage, during the process of application with a 
paint-brush. 

Silicate of soda, of potassa, or of magnesia, have also been employed 
in the same manner. Of these the silicate of soda is the least expen- 
sive, and equally firm. A saturated solution is prepared, and applied 
with a brush. It hardens rather slowly, but forms a light, firm, and neat 
splint. Wheat-Hour paste, if properly made, dries about as quickly as 
the starch, and is equally firm. 

Whatever material is used — whether starch, flour paste, dextrin solu- 
tions of the silicates, gum shellac, or plaster of Paris — in the construc- 
tion of what is now usually termed the "immovable apparatus," or, as 
Seutin has more lately called it, the "movable immovable apparatus" 
("movo-amobile"), in reference to his practice of opening it at an early 
period, it is still the same apparatus in effect, and is liable to the same 
judgment — a judgment which we shall find it very difficult to declare, 
since, from the day in which this practice was first recommended by 
Seutin, to the present moment, it has been constantly experiencing the 
most extraordinary vicissitudes in the public favor. At one time, and 
by the most experienced surgeons, extolled as a method unequalled in 



64 



GENERAL TREATMENT OF FRACTURES. 



its simplicity, efficiency, and safety ; and at another, and by surgeons 
of equal experience, denounced as eminently lacking in all of the true 
essentials of an apparatus for broken limbs. These conflicting opinions, 
which it is impossible to reconcile, have nevertheless some foundation in 
truth. The immovable apparatus, of whatever materials constructed, is 
under some circumstances a very simple, safe, and efficient dressing, while 
under other circumstances it is, as we think, eminently unsafe and ineffi- 
cient. Thus, in all of those fractures which are accompanied with such 
injury to the soft parts as to render subsequent inflammation inevitable 
or probable, this form of dressing exposes to congestion, strangulation, 
and gangrene. Whatever its advocates may say to the contrary, the 
simple fact is before us, that the number of accidents resulting from this 
practice is out of all proportion with any other yet introduced. I have 
met with them myself in all parts of my own country, and the journals 
abound with records of disasters from this source. 1 Nor is it a sufficient 
reply to this statement, that, with proper care and prudence, such acci- 
dents may be avoided. We think they could not always be avoided. 
But admitting that they could, it is still undeniable that in certain cases, 
the immovable apparatus demands extraordinary attention ; and what is 
the need of multiplying our cares when already they are more than suffi- 
cient ? Many circumstances, over which he has no control, may prevent 
the surgeon from (riving to the limb the full amount of attention which is 
required ; and for this reason that apparatus is the best which, whilst it 
answers the indications equally well, exacts the least amount of skill and 
attention on the part of the surgeon. 

Fig. 13. 




Opening of the apparatus with Seutin's pliers. 

Immovable dressings are not only liable to become too tight as the 
swelling augments, but, on the other hand, the surgeon may omit to 
notice that as the swelling has subsided it has become loose. Portions 
of the limb may vesicate, ulcerate, or even slough, without the know- 
ledge of the surgeon. If, however, the bandages are frequently opened, 
and all the proper precautions are taken, it is possible that these acci- 
dents may also be avoided ; but unfortunately experience has shown that 
they have not been avoided in too many instances. 



1 Araer. Journ. Med. Sci., vol. xxv. p. 460, Fab. 1840 ; also vol. xxxi. p. 212. 
Mei. Record, Nov. 1, 1873; New York Med. Journ., Aug. 1874, Oct. 1874. 



GENERAL TREATMENT OF FRACTURES 



65 



Fig. 14. 



The cases, then, to which this apparatus seems to be especially adapted, 
are a few examples of transverse or serrated fractures in which the bones 
have not become displaced, and in which little or no swelling is antici- 
pated ; and certain fractures which were originally more complicated, 
but in which a partial union, and the subsidence of the inflammation 
have reduced them to a more simple condition ; and especially is it 
adapted to cases of delayed union. If now the dressings are applied 
carefully, the bandage being only moderately tight ; and a portion of the 
extremity of the limb is left uncovered so that we may observe con- 
stantly its condition, and at proper intervals the apparatus is opened 
completely, in order that we may subject the whole limb to a thorough 
examination ; in such cases as we have now indicated, and with such 
precautions, we admit that the " apparatus immobile" constitutes an in- 
valuable surgical appliance, and one of which no surgeon can well afford 
to be deprived. 

I have even met with examples of compound fractures in which it has 
seemed proper to apply this dressing ; and especially when a sufficient 
time had elapsed to render it probable that there 
would be no sudden accession of swelling in the 
limb. In such cases I have preferred generally 
to lay the several turns of the roller directly over 
the suppurating wound in the same manner as if 
no wound existed, and to make a valvular open- 
ing, or window, with the scissors, on the follow- 
ing day, in order to allow the matter to escape, 
after which the valve may be laid down and 
stitched, or the piece may be removed entirely, 
and a new piece of bandage drawn closely around 
the limb at this point. This may be repeated 
once or twice daily. If an opening is left by the 
roller, and no additional bandage or compress is 
laid over it, the margins of the wound soon be- 
come (Edematous and protrude, making an ugly- 
looking and ill-conditioned sore. 

Plaster-of-Paris moulds, employed occasionally 
from a very early period, and more lately recom- 
mended by Hendriksz, Hubenthal, Keyl, and 
Dieffenbach, are not entitled to serious consider- 
ation. Heavy stone coffins, they might serve 
well enough the purposes of interment, but they 
are wholly unsuited to the purposes of a splint. 

Plaster of Paris has, how r ever, been from a 
later period employed in another form, as an " immovable" dressing. 
I allude to the so-called " plaster-of-Paris bandages," which were first 
introduced to notice by Mathiesen, of Holland, in 1852. In 1854, Pi- 
rogoff, surgeon in chief of the Russian armies, called attention to the 
plaster-of-Paris dressings, but in a form differing somewhat from that 
employed by Mathiesen. 

Recurring to the history of the immovable dressing, as briefly narrated 
in the preceding pages, and as more fully recorded in the medical journals 




"Apparatus immobile" ap- 
plied over a compound frac- 
ture. 



bb GENERAL TREATMENT OF FRACTURES. 

of the next eighteen or twenty years, we shall find that it had steadily 
declined in public favor, on account of the numerous accidents resulting 
from its use, many of which became the subjects of litigation in the 
American courts ; so that neither the suggestions of Mathiesen in 1852, 
nor the great name and influence of PirogofF in 1854, nor the advocacy 
of Hunt, of Birmingham, in 1855, nor of Gamgee in 1856, were suffi- 
cient to secure for plaster of Paris the confidence of the profession. The 
period was unfortunate, and surgeons were scarcely willing to give these 
gentlemen a respectful hearing, inasmuch as they at once recognized 
these modes of using plaster of Paris as only modifications of the method 
of Seutin, which, for good reasons, they had just laid aside. 

Since Mathiesen wrote, however, a new generation has arisen ; a gen- 
eration of active, able, and hopeful men ; with no prejudices of experi- 
ence to overcome ; to whom the " primary bandage" and Seutin's " ap- 
paratus immobile," convey no apprehensions of danger ; and now again, 
following this time the lead of the German surgeons, we find these 
methods in popular favor, both at home and abroad. It will be the part 
of wisdom, while we observe carefully the experience of the present, to 
recall the lessons of the past. 

At Bellevue, during six or seven years, plaster-of-Paris bandages 
were used quite extensively, and, after a careful observation of the 
results in my own wards and in the wards of my colleagues, I find no 
occasion to recall anything I have said of this, as one form of the im- 
movable apparatus, in the preceding pages ; the dangers have not been 
overestimated, yet I must say that in fractures of the leg, whether 
simple or compound, when great care is exercised in the management of 
the case, it is in some respects superior to any other form of dressing. 
I shall describe the cases to which it is applicable, more particularly, 
when speaking of these fractures. At the present moment the use of 
plaster of Paris as a dressing for fractures is very little in favor with 
most of the Bellevue surgeons*, except in fractures of the tibia and fibula. 1 

The manner of using gypsum bandages, generally preferred at Belle- 
vue Hospital, may be thus briefly described. Thin, rather coarse un- 
glazed cotton cloth, torn into strips, is laid upon a table and the dry 
plaster rubbed into it until its meshes are full. It is then rolled, and 
made ready for use by immersing it a few minutes in hot w T ater. The 
limb, being held in a proper position, is first inclosed in soft dry flannel 
cloth, and the rollers are then applied. In most cases two or three 
thicknesses of bandage are found to be sufficient. A more full descrip- 
tion of this method, known generally as Mathiesen's, will be found in 
the chapter devoted to the consideration of fractures of the femur. 

Another method of using the gypsum bandages, not generally prac- 
tised at Bellevue, is as follows : A dry roller is first applied to the 
limb, or it may be covered with a single piece of cloth of any kind, and 
the irregularities are filled up and protected w T ith cotton-wool, the same 

1 Treatment of Fractures of the Femur by the Immovable Apparatus, by the au- 
thor. New York Med. Journ., Aug. 1874. A comparison of the results of treatment 
of 308 fractures of the thigh at Bellevue Hospital, by Frederick E. Hyde, M.D., New 
York Med. Journ., Oct. 1874. 



GENERAL TREATMENT OF FRACTURES. 67 

as we have directed when about to apply the starch bandage. The 
remaining dressings being now at hand and ready for use. we proceed 
to mix the plaster. For this purpose we must select the fine, fresh, 
well-dried, white powder. The gray does not solidify well, nor that 
which has been a long time ground, or is moist. The proportions of 
water and plaster usually required are about equal parts by weight. 
For the thigh it may require, perhaps, seven or eight pounds of plaster, 
and for the leg or arm much less. It is probably a better rule to 
direct the gypsum to be added to the water until it is of about the con- 
sistence of cream. The water should be cold and the gypsum thrown 
in not too rapidly, at least not more rapidly than it can be thoroughly 
mixed, otherwise we shall not be able to determine precisely its con- 
sistence. If, while applying the paste, it begins to harden in the bowl, 
we must not add more water, as this will again interfere with its final 
solidification upon the limb. It must be thrown away and some fresh 
immediately prepared ; or the crystallization may be retarded by throw- 
ing in a few drops of carpenters' glue, or a little starch, dextrin, or 
glycerin. The solidification may be hastened by adding a little salt to 
the water. When the plaster is good, and it is properly mixed, we 
may allow ourselves from five to eight minutes in the application. A 
large paint-brush is the most convenient thing for spreading it, but the 
hands will do very well in an emergency. 

Everything being ready, the limb is to be seized by assistants at 
both of its extremities and held in a position of steady extension until 
the dressing is completed, and for several minutes longer, or until the 
plaster is hard. The surgeon then proceeds to lay a long piece of linen 
— old sack will answer as well as any- — folded three or four times, and 
saturated with the paste, parallel to the two sides of the limb, around 
which are to be immediately placed, horizontally and at several points, 
short and wide strips of the same material. These latter are intended 
to increase the strength of the apparatus, and to bind on the side strips. 
Finally, the whole may be painted with the solution. It is very well, 
how r ever, not to cover the front of the limb, or a narrow strip somew T here 
in the line of the axis of the limb, with the plaster, as this will not 
diminish materially its strength, and it will enable the surgeon to open 
it more easily with the scissors. Pirogoff accomplishes the same pur- 
pose by laying a piece of narrow tape, soaked in oil, along the line 
through which he wishes to make the section of the splint. 1 

Prof. James L. Little, of New York, makes his plaster splints of two or 
three thicknesses of muslin, or of canton flannel, which, being saturated 
with fluid plaster, are laid upon the limb previously shaven and oiled, 
and secured in place with a roller. He advises that the roller shall be 
removed as soon as the plaster is set and a fresh one applied, which can 
afterwards be easily removed. 2 

Some surgeons prefer to construct the plaster splint in the following 
manner: Two pieces of flannel are laid one upon the other, and being 

1 Weber on Plaster-of-Paris Bandage, New York Jonrn. Med., May, 1856, p. 341. 

2 Little. On the Use of Plaster of Paris in the Treatment of Fractures, by James 
L. Little, Surgeon to St. Luke's Hospital, etc., Med. Record, Nov. 1, 1873. 



68 



GENERAL TREATMENT OF FRACTURES. 



stitched by a straight seam along the centre, the inner layer is carefully 
folded around the limb, and made fast by a needle and thread. Fluid 
plaster is now spread over the outer surface of the inner layer, and the 
inner surface of the outer layer, when the two are brought in contact 
upon the limb, and the whole secured by a roller. After the splint is 
thoroughly dry it may be cut in front and opened like the cover of a 
book. Hence it has been called the " book-back" method. It is also 
known as the Bavarian. 

There are other modifications of the methods of using plaster of Paris, 
which will be more appropriately described in connection with special 
fractures. 

Drs. Wm. A. Byrd, Frank Green, and others have devised simple 
machines for the purpose of filling the tissue of the cloth with powdered 
gypsum while it is being rolled. 1 Such an apparatus might be very 
useful in an hospital, as a means of saving time, but it is scarcely needed 
in private practice. 

In removing the plaster we generally employ a shoemaker's knife, 
softening the plaster as we proceed with a sponge dipped in hot water. 
As cutting pliers for this purpose, no instrument has been found suf- 
ficiently powerful except that introduced by Dr. Victor von Brun, of 



Tiibingen. 



Fig. 15. 




Von Brun's plaster-cutter. 

Professor B. W. Dudley, of Lexington, Ky., one of the most success- 
ful surgeons in this country, but especially distinguished as a lithoto- 
mist, for many years employed in the treatment of fractures nothing 
but a roller, regarding both side-splints and extending apparatus as 
not only useless, but absolutely pernicious. 2 This practice, which seems 
to have originated with Radley, of England, has not found, hitherto, in 
this country or elsewhere, many imitators. 

Still more unscientific and irrational was the practice of Jobert, of 
Paris, who employed neither side-splints nor bandages, but only exten- 
sion, in the treatment of all, or of nearly all fractures of the long bones. 
The side or coaptation splints bring the fragments into more complete 
apposition, and secure a more prompt and certain union. They ought, 



' Med. Record, Oct. 13, 1877, p. 655. 

2 Dudley, Trans. Amer. Med. Assoc, vol. iii., 1850, p. 349. 



GENERAL TREATMENT OF FRACTURES. 69 

therefore, never to be omitted, unless the condition of the limb precludes 
their application. 

As to the question of permanent extension in fractures, and the means 
bj which it may be most effectually accomplished, nothing need be said 
at this time, inasmuch as it relates only to the fractures of certain bones, 
and to certain forms of fractures ; we must therefore refer its considera- 
tion to those chapters which treat of individual bones. 

In the treatment of comminuted fractures, no pains ought to be spared 
to bring the fragments as nearly as possible into apposition ; and if there 
exists at the same time an external wound, and the fragments are small 
and loose, they ought to be removed carefully. Nor, indeed, should we 
be deterred from the attempt to remove them by finding that they are 
somewhat adherent, if still they are very easily moved about with the 
finger. 

In compound fractures, not unfrequently the end of one of the frag- 
ments protrudes from the wound, and its reduction may be attended with 
considerable difficulty. My practice is usually in such cases to attempt 
the reduction first, by simple extension and counter-extension ; but if 
this fails, a finger is introduced into the wound, and an attempt is made 
to stretch the skin over the sharp point of bone ; or a spatula is used, 
formed from a piece of wood, or of any suitable piece of metal which 
may be at hand ; finally, but not until all other expedients have failed, 
the wound is enlarged sufficiently to insure its return. Anaesthetics 
may be employed, also, to facilitate the reduction. 

There are some cases, however, in which the surgeon may feel justi- 
fied in sawing off the projecting end ; as when the periosteum is com- 
pletely torn from it by its having penetrated a boot, or even sometimes 
when its extremity is very sharp, and there is reason to suppose that it 
would prick and irritate the tissues. In these cases, also, surgeons have 
proposed to secure the fragments in apposition by metallic ligatures or 
sutures. In a few instances the practice has been attended with suc- 
cess, but in most cases the wires have failed utterly of their purpose, 
and have only proved sources of additional irritation. 

Ruptured arteries, if within reach, ought always to be tied ; and if 
arteries situated remote from the surface bleed freely and for a long 
time, we may make some effort to find the open mouths in the wound ; 
but in this we rarely succeed, nor is it safe generally to trust to a liga- 
ture of the main branch which supplies the limb. Fortunately, this 
bleeding, although at first profuse, generally ceases in a few hours under 
the steady employment of cold lotions, moderate compression, and rest. 
If it does not, the chances are that the case will call for amputation. 

The rule generally laid down by surgeons, that we should at once 
close the wound in compound fractures, with sutures and adhesive straps 
if necessary, or with bandages, is far too absolute. This practice will 
do when there is no great contusion or extravasation of blood ; but if 
blood is flowing, it is much better to leave the wound open, so as to per- 
mit it to escape freely ; and if the severity of the injury warrants the 
supposition that much inflammation is to ensue, the danger of gangrene 
is greatly lessened by thus allowing the opening to remain as a channel 
of exit for the inflammatory effusions. 



70 GENERAL TREATMENT OF FRACTURES. 

It has, however, been claimed of late bj Mr. Lister, of Edinburgh, 
and by many others who have adopted his practice, that by the use of 
carbolic acid in the manner which will presently be described, we may 
again return safely to the old practice of closing at once all wounds con- 
nected with fractures, without regard to the degree of contusion, lacera- 
tion, or comminution ; indeed, it is affirmed that by the adoption of this 
method of treatment we may avoid suppuration and its consequences in 
a very large proportion of cases. It is believed by Mr. Lister that sup- 
puration is mainly due to the presence of certain germs which constantly 
float in the air, and which carbolic acid is fully able to destroy. Every 
possible precaution is therefore taken to exclude the air, and to disinfect 
that which is unavoidably brought in contact with the wound. The in- 
terior of the fresh wound is fully injected with carbolic acid of the 
strength of one part of carbolic acid to twenty of water ; nor does he 
hesitate to throw this into wounds communicating with joints. The 
fluid being afterwards carefully expressed, the surface of the wound is 
covered first by the " protective," which is a piece of oiled silk coated 
with a thin layer of a mixture composed of one part of dextrin, two of 
powdered starch, and sixteen of a cold solution of carbolic acid ; the lat- 
ter being of the same strength as the solution employed for injecting the 
wound ; or a piece of oiled silk, covered upon one side with shellac var- 
nish, is applied. Over this is laid a piece of gauze, soaked in fresh car- 
bolic solution, followed by half a dozen layers of the same material, a 
piece of mackintosh cloth, and finally the antiseptically prepared gauze 
roller is applied carefully and lightly. Meanwhile carbolized spray from 
an atomizer is constantly thrown upon the parts until the dressings are 
completed. In certain cases a drainage tube, treated with carbolic acid 
solution, is left in a depending portion of the wound. All the subsequent 
dressings are to be made with equal care and formality. The knives 
and other instruments employed are to be thoroughly washed in the car- 
bolized solution ; also the hands of the surgeon, and whatever else 
may come in contact with the wound. 

The reputation enjoyed by Mr. Lister, and the distinguished names 
reckoned to-day among his disciples, afford a guarantee that, as against 
certain other methods, it ought to have a preference, and that its actual 
claim to a superiority over all other methods is entitled to respectful 
consideration. Nevertheless, while I admit its excellence, I am far from 
being convinced that, in the case of compound fractures or of other 
wounds, it is capable of doing all that is claimed for it. I do not believe 
— indeed from actual experience I know — that the knee-joint cannot be 
" freely laid open" under the Lister treatment " with the certainty that 
no danger will follow." 1 Nor have I seen compound fractures treated 
any more satisfactorily or successfully by this method than by methods 
employed by myself and others. Only very recently a compound frac- 
ture of the leg, in one of our best metropolitan hospitals, was progressing 
rapidly from bad to worse under this plan, the limb becoming more and 
more inflamed and swollen and being threatened with gangrene, when, 

1 Joseph Lister, F.R.S. Remarks at the International Med. Congress, in Philadel- 
phia, 1876. Transactions, p. 535. 



GENERAL TREATMENT OF FRACTURES. 71 

the hot water dressing being substituted, the inflammation speedily 
subsided, and the limb was saved. It is impossible to exclude atmos- 
pheric germs from wounds which have been long exposed to the air 
before they are placed under antiseptic treatment, and it can easily be 
shown that absolute exclusion of air does not prevent, necessarily, sup- 
puration and decomposition in those cases, nor insure against the pre- 
sence of bacteria. That carbolic acid and many other antiseptics do this 
to some extent is true ; but this is all that can be justly claimed for any 
of the antiseptics : and this is no more than surgeons have understood 
for a long time. 

In short, if the method of Mr. Lister has any advantages, and it no 
doubt has, these advantages consist in the continuous application of a 
mild stimulating lotion, in the exercise of great care and tenderness in 
the removal and reapplication of the dressings, in the absolute rest im- 
posed, in the occasional use of the drainage tube, and in the antiseptic pro- 
perties of the carbolic acid, and not, as has been taught by some sur- 
geons, exclusively, or even mainly, in the employment of an antiseptic. 

Most wounds, including the wounds caused by fractures, need at the 
first, and not unfrequently during the whole course of their treatment, 
a certain amount of gentle stimulation, such as dilute carbolic acid is 
capable of causing ; and especially is this true since the introduction of 
anaesthetics, which suspend for a time many of the vital forces, and cause 
a delay in the effusion of organizable materials, and in the process of 
repair. Carbolic acid, or any other mild stimulant, hastens the return 
and accelerates the progress of this repair. 

The really essential things in the successful treatment of compound 
fractures are, that no additional injury shall be done to the limb by rude 
handling — by thrusting the fingers and instruments unnecessarily into 
the wound — by forcible extraction of slightly detached fragments — by 
violent wrenching and pulling of the limb in order to complete a diag- 
nosis, or to adjust the fragments, or to wholly overcome the shortening 
— by tight bandages or badly adjusted splints ; that the sponges and 
other materials applied to the sore shall be free from infectious agents ; 
that the dressings be not disturbed too often, but often enough ; that 
each dressing be made without disturbing the limb, or in any degree in- 
flicting pain upon the patient ; that pent-up matter is timely evacuated, 
but not rudely pushed out by manual pressure. The limb has enough to 
contend with in the original accident, without the added dangers of rough 
handling, or of probing, so generally practised by badly-trained nurses, 
and badly-trained and reckless surgeons. 

Drainage tubes are no doubt often useful and even essential ; but they 
are as capable of doing harm as of doing good. They may be thrust in 
and drawn out from time to time unnecessarily, often causing pain and 
haemorrhage ; or they may be allowed to become blocked, and thus ac- 
tually dam up the fluids instead of facilitating their escape. In short, 
in many cases they are wholly unnecessary, and in some injurious. 

To insure absolute rest to the limb some very light but firm splints 
may be employed to secure immobility, or a plaster-of-Paris splint, and 
the limb may require to be suspended ; but these are points upon which 
the surgeon must use his own judgment. 



72 GENERAL TREATMENT OF FRACTURES. 

If inflammation threatens the safety of the limb it may be necessary 
to remove all apparatus, or splints, and to wrap the limb in sheet-lint 
saturated with water at a temperature of 95° or 100° Fahrenheit ; or if 
gangrene has occurred, or its occurrence is imminent, water at a tem- 
perature of 105° or 110° should be substituted, and this elevated tem- 
perature should be maintained assiduously by constant or very frequent 
flooding with the hot water. 

There are no circumstances known to me when, according to my later 
experience, it would be proper to apply ice or cold dressings in com- 
pound fractures, unless it be to restrain haBmorrhage. 

Bleeding is rarely if ever necessary, and in a large majority of cases 
it would prove injurious by lowering the vital forces, which need to be 
husbanded in view of the requirements of the process of repair, and of the 
probable long and exhausting confinement. It might even prove speed- 
ily fatal by adding to the immediate depression. 

Cathartics should also be administered cautiously for the same reason ; 
and because they are liable, and especially in fractures of the lower ex- 
tremities, to occasion a serious disturbance of the limb. 

Many years since, Dr. J. Rhea Barton introduced into the Pennsyl- 
vania Hospital what has since been called the "bran dressing" for the 
treatment of compound fractures of the leg ; the limb being made to 
repose in a box filled with this material. 1 I have used it very fre- 
quently in Bellevue and in other hospitals, and can speak of it as pos- 
sessing many qualities of excellence, especially as a summer dressing. 
The peculiar mode of using this apparatus I shall describe more minutely 
when treating of fractures of the leg. 

Bones badly united. — Bones which have united with serious deformity 
are occasionally refractured for the purpose of securing a more comely 
or a more serviceable limb. This may be done when the union is recent 
and the callus and adjacent tissues are vascular, with almost an assurance 
of a prompt union. Indeed, if the bone be refractured within four or 
eight weeks after the occurrence of the original fracture, it will in gene- 
ral unite more speedily than at first ; but if the refracture is delayed 
much beyond the latter period, the chances of prompt reunion become 
lessened, and after the lapse of several months or years the danger that 
a refracture will result in only a fibrous union is considerable. In the 
case of an old fracture it becomes therefore a question whether the de- 
formity and maiming are sufficient to warrant the surgeon in assuming 
the risk that it may not unite at all or that it may result in a fibrous 
union. The cause of this delay and uncertainty in the proper union 
after refracture of bones which have been long united, is probably the 
fact that the bond of union becomes at length harder than the original 
bone, and although it may break as easily as, or even in most cases more 
easily than, the natural bone, it is less vascular, and the tissues adjacent 
are also perhaps less vascular, having undergone certain textural or cica- 
tricial changes in consequence of this prior lesion. 

In deciding this question then we will be governed by the degree of 
deformity and maiming, by the time which has elapsed since the union, 

> Amer. Jour. Med. Sci., May, 1835. p. 31 ; April, 1842, p. 515. 



DELAYED AND NON-UNION OF BROKEN BONES. 73 

and by the general condition of the patient as to constitutional vigor 
and capacity of repair. 

There is one popular error in reference to refracture, and indeed the 
error is by no means confined to the laity, namely, that by a refracture 
at any period after four or six weeks we can materially add to the length 
of the limb. The permanent contraction of the muscles which by this 
time has taken place, the presence at an early stage of inflammatory 
effusions, and at a later stage of adhesions, will in most cases effectually 
prevent any considerable elongation of the limb. It may be lengthened 
by being rendered more straight, and in a small degree perhaps by 
actual stretching of the soft tissues, but this is all that can be reasonably 
promised or expected. 

In general no fear need be entertained that the refracture will en- 
danger the life of the patient. No doubt death may have been caused 
in this way, but a scientifically conducted refracture is vastly less likely 
to cause death than the original accident. Nor need we generally fear 
that the bone will break at any other point than at the place of the old 
fracture, provided at least we take proper care to make the pressure at 
the right point ; we have no need therefore of an osteoclast, such as 
was devised by Rizzoli, and later by Taylor, with which they proposed 
however only to break limbs which were anchylosed in positions which 
rendered them useless. 1 



CHAPTEE VII. 

DELAYED UNION, FIBROUS UNION, AND NON-UNION OF 
BROKEN BONES. 2 

Causes and Varieties. — Most surgical writers concur in the state- 
ment that non-union of broken bones is an uncommon event. Walker of 
Oxford, affirms that of not less than one thousand fractures which have 
come under his treatment at some period of the repair, he does not 
recollect more than six or eight instances. According to Lonsdale, not 
more than five or six cases of false joint, excepting those within a cap- 
sule, have occurred out of nearly four thousand fractures treated at the 
Middlesex Hospital. In a table of 367 cases, collected and arranged by 
W. W. Morland, from the books of the Massachusetts General Hospital, 
extending through a period of nineteen years, only one example of false 
joint is recorded ; but as only seventy-four days had elapsed when this 
patient was discharged, it is doubtful whether this might not have proved 

1 The Medical Record, April 21, 1877. 

2 I shall in this chapter avail myself freely of the labors of George W. Norris, of 
Philadelphia, whose paper, entitled "On the Occurrence of Non-union after Frac- 
tures, its Causes and Treatment," published in the American Journal of the Medical 
Sciences for Jan. 1842, constitutes one of the most complete and reliable monographs 
upon this subject contained in any language. 

6 



74 DELAYED AND NON-UNION OF BROKEN BONES. 

to be a case of delayed union simply. 1 In 946 cases of recent fracture 
treated in the Pennsylvania Hospital, between the years 1830 and 
1840, there was no instance of false union, 2 Sir Stephen Hammick, Mr. 
Liston, and Malgaigne affirm also the infrequency of these accidents 
in the cases which have come under their personal treatment. I have 
myself seen a large number of examples of non-union, but in not one of 
my own patients, whether in hospital or private practice, except in 
cases involving joints, has the bone refused finally to unite ; and my 
opinion is, that, in proportion to the number of fractures everywhere, 
these cases are very rare, perhaps not in a larger proportion than one 
in five hundred. 

The humerus and femur would appear to be the bones most liable to 
non-union, as shown by Norris's statistics; in which forty-eight belonged 
to the humerus, forty-eight to the femur, thirty-three to the leg, nineteen 
to the forearm, and two to the jaw. In my own experience, I have 
found the humerus ununited more often than the femur. 

Berard has shown that in the growth of the long bones the period at 
which the epiphyses are united to the diaphyses depends upon the di- 
rection of the nutritive artery ; for example, " It is found that in the 
humerus, where the direction of this vessel is from above downwards, 
consolidation takes place soonest at its inferior extremity. In the fore- 
arm, the course of the nutrient vessels is from below upwards, and here 
consolidation of the epiphyses is found to occur at the elbow sooner than 
at the wrist. In the inferior members, on the contrary, the epiphyses 
composing the knee are the last which become firm, because in the femur 
the nutritious artery runs upwards, and in the bones of the leg it courses 
from above downwards." A knowledge of these facts led Gueretin to 
inquire into the influence of these arteries upon the consolidation of 
fractures ; and the cases collected by him did indeed seem to show a 
positive relation between the direction of the artery and the union of 
the bone ; that is to say, the examples of non-union were chiefly found 
where the fracture had taken place on that side of the nutritious foramen 
from which the artery entered, as if to imply that the non-union was in 
some measure due to the imperfect nutrition of this extremity of the 
bone. In thirty-five cases of non-union analyzed by GueVetin, ten be- 
longed to that portion of the bone which was traversed by the artery, 
and twenty-five to the other portion. But an analysis of forty-one cases, 
made by Norris, does not seem to confirm this observation of Gueretin, 
since twenty-seven were in the direction of the nutritious arteries, and 
only fourteen in the opposite portion, or in that which is supposed to be 
less nourished. 

Another observation, made by Curling, that in fractures of the long 
bones the portion below the entrance of the nutrient artery, or on that 
side of the nutrient foramen toward which the blood flows, being de- 
frauded of its proper supply, is subjected to a species of atrophy, pre- 
senting a larger medullary canal, with thinner walls, and a spongy tissue 



1 Address on Fractures, by A. L. Pierson, read before the Massachusetts Med. Soc 
May 27, 1840. 

2 Norris, loc. cit. 




DELAYED AND NON-UNION OF BROKEN BONES. 75 

less dense, also needs confirmation. Malgaigne has not noticed this fact 
in any of the specimens contained in the public museums of Paris ; and 
we do not know that any other writer has made the question a subject 
of especial inquiry. 

According to Norris, there are four principal kinds of false joint: — 

In the first, the bones are united and completely enveloped in a car- 
tilaginous mass or callous tumor, but, in consequence of some retardation 
in the process, bony matter is not deposited, and, as a consequence, it 
wants solidity, the part continuing easily movable. This may be regarded 
as a proper example of delayed union, as distinguished from complete 
non-union, or false joint. 

In the second, there is entire want of union of any sort between the 
fragments, the ends of which seem to be diminished in size and extremely 
movable beneath the integuments. The limb in these cases is found wasted 
and powerless. 

In the third and most common class, the medullary canal is obliterated 
in both fragments, and the ends are more or less absorbed, rounded, and 
covered, in part or in whole, with a 

dense tissue resembling the periosteum. FlG - 16, 

A connection also exists between the 
opposing fragments in the form of 
strong ligamentous or fibro-ligament- 

00 . •!* p Clavicle united by ligamentous bands. 

ous bands, which, 11 of any length, 

are quite flexible, and allow of considerable motion at the seat of frac- 
ture. 

In the fourth, " a dense capsule without opening of any kind, contain- 
ing a fluid similar to synovia, and resembling closely the complete liga- 
ments, is found." In these cases the points of the bony fragments 
corresponding to each other are rounded, smooth, and polished, in some 
instances eburnated, and in others covered with points or even thin plates 
of cartilage, and a membrane closely resembling the synovial of the 
natural articulation. It is in this kind of cases, Norris remarks, that 
the member affected may still be of use to the patient, the fragments 
being so firmly held together as to be displaced only upon the applica- 
tion of considerable force. 

The existence of these newly-formed joints, or true diarthroses, has 
been called in question by Boyer, Hewson, Chelius, 1 and others ; but the 
observations of Sylvestre, Brodie, Beelard, Home, Howship, Otto, Kuhn- 
holtz, Houston, Cooper, Langenbeck, and Breschet prove that such ex- 
amples are occasionally found. 2 I have myself met with several exam- 
ples. 

A case is reported as having occurred in Boston, Massachusetts, in 
which a young man, set. 18, broke his humerus near its middle. Before 

1 Malad. Chirurg., t. iii. p. 103, Paris, 1831 ; North Amer. Med. and Surg. Journ., 
No. ix. p. 7, 1828 ; Trait, de Chir., trad, par Pigne, p. 150, 1836. (Norris, loc. cit.) 

2 Nouvelles de la Repub. des Lettres de Bayle, p. 718, 1685 ; Lond. Med. Gaz., xiii. 
p. 57, 1833 ; Beclard, Gen. Anat., trans, by Hayward, pp. 149, 248 ; Transac. Med.- 
Chir. Soc. of Edinburgh, i. p. 233, 1793 ; Med.-Chir. Trans., viii.p. 517, 1817 ; Otto's 
Path. Anat., trans, by South, i. p. 138 ; Journ. Complement., iii. p. 291 ; Dub. Med. 
Journ., viii. p. 493; Cooper on Frac. and Disloc, fourth London ed., p. 508; Ee- 
cherch. sur les Formation du Cal, 1819, p. 34. (Norris, loc. cit.) 



76 DELAYED AND NON-UNION OF BROKEN BONES. 

union had been completed it was accidentally refractured, and from this 
time the fragments showed no disposition to unite ; on the contrary, a 
gradual process of absorption took place, until at length the whole of the 
humerus disappeared ; and that, too, " without any open ulcer." Eigh- 
teen years later he was perfectly well, and the arm was strong and useful, 
but no portion of the bone had been reproduced. 1 

Norris is a disciple of Dupuytren, and accepts his doctrine of the 
formation of callus, without reservation ; consequently he finds no ne- 
cessity for but one form of delayed union, namely, that which we have 
described as belonging to the first class. In all of this class he assumes 
the existence of a cartilaginous ring or ferrule ; but we think the error 
of this exclusive theory has been sufficiently shown by the observations 
of Paget and others, and we should be warranted therefore in affirming; 
the existence of as many varieties of delayed union as there are varieties 
in the manner and position of the deposit of callus, even if their actual 
existence had not been repeatedly demonstrated by dissections. 

The causes of delayed union and of non-union are either constitutional 
or local. 

The constitutional causes are chiefly those conditions of the general 
system which manifest themselves by anaemia, debility, or some peculiar 
dyscrasy. 

Sanson, Beulac, Condie, 2 and many others have mentioned cases in 
which the existence of syphilis in the system has seemed to prevent the 
formation of callus ; but, on the other hand, Lagneau and Oppenheim 3 
incline to the opinion that syphilis exerts in this respect but little influ- 
ence ; and even Berard, who admits the pertinence of one case observed 
by Nicod, concludes, after numerous researches, that it has been very 
rarely shown to affect the formation of callus. 4 

Pregnancy and lactation have been known to interfere with the union 
of bones. Werner, Hildanus, Wilson, Hertodius, Alanson, Bard, of 
New York, and Condie, of Philadelphia, 5 have all reported examples, 
in some of which the process of union was resumed and brought to a 
rapid completion so soon as the period of pregnancy was closed, or when 
lactation ceased ; but three cases reported by Sir Stephen Love Ham- 
mick would seem to show, what, indeed, other evidences render probable, 
that the delay was less due to the fact of the pregnancy and the lacta- 
tion than to the debility occasionally consequent upon these conditions. 6 

As to the question whether cancer ever causes a delay in the union 
of bones, it may be said that where the fracture arises in consequence 
of a true cancerous deposit around or in the interior of the bones, pro- 
ducing absorption of their tissue, no union takes place ; but that the 

1 Boston Med. and Surg. Journ., July 11th, 1868, p. 368. 

2 Diet, de Med. et Chir. Prat., iii. p. 492 ; Journ. de Med. Chir. et Pliarm., t. xxv. 
p. 216. (Norris, loo. cit.) 

3 Expose des symp. de la mal. Ven., p. 525 ; Oppenheim on False Joints, 1837. 
(Norris, loc. cit.) 

4 Op. cit., p. 21. 

5 Cooper's Die, ed. 1838, p. 546 : Opera Hild., 1681 ; Wilson on the Human Skele- 
ton, p. 214; Bib. Choisie de Med., xxiv. p. 595 ; Med. Obs. and Inquiries, 4, 1772; 
Philosoph. Trans., xlvi. p. 397, 750. (Norris, loc. cit.) 

6 Practical Remarks on Amputations, Fractures, etc., p. 121. (Norris, loc. cit.) 



DELAYED AND NON-UNION" OF BROKEN BONES. 77 

mere presence of the cancerous cachexy does not usually prevent the 
formation of callus. 

Scurvy, fevers of a low type, and, on the other hand, fevers of a 
highly inflammatory character, profuse uterine and vaginal discharges, 
and rachitis, conduce to the same result. 

The withdrawal of an habitual stimulus, and especially a change from 
a good to a low diet, or copious bleedings, may either of them delay the 
deposit of ossific matter, or prevent it altogether. 1 

Bonn has furnished two cases in which advanced age seemed to have 
retarded the formation of callus, but Horner saw a fracture of the hume- 
rus in a woman ninety years old unite in five weeks. 2 I have myself 
noticed a good many similar examples in advanced life, and it is now 
rendered quite probable that surgeons have generally overestimated the 
influence of old age upon the formation of callus. 

The local causes are, arrest of the arterial circulation by bandages ; 
arrest of the venous circulation by pressure, by rupture of veins, or by 
the formation of venous clots ; 3 paralysis or impairment of the nervous 
circulation ; the occurrence of the fracture within a capsule ; obliquity 
of the fracture ; overlapping of the fragments ; interposition of a piece 
of bone, of a tendon, muscle, or of a clot of blood, or separation of the 
fragments from any cause whatever ; erysipelas ; acute phlegmonous 
inflammation ; suppuration ; necrosis ; too much motion ; exclusion of 
light and air inducing local scurvy ; wet, and especially cold and moist 
dressings ; too early use of the limb, etc. 

Treatment. — In order to hasten the consolidation when it is simply 
delayed, we resort to all of those expedients which are calculated to in- 
vigorate the general system ; and for this purpose the employment of a 
nutritious diet and the use of mineral or vegetable tonics may not be 
properly omitted ; but in our experience nothing has proved so efficient 
as encouraging the patient to leave his bed and get out into the open air ; 
for which purpose, if the fracture is in the lower extremities, crutches 
will be necessary. 

As local means, we may enumerate first the removal of those local 
causes which seem to have interfered with the consolidation or with the 
union. If the fragments have been officiously disturbed, it may be 
sufficient to impose upon the limb absolute rest for a certain length of 
time ; and the fragments may be more closely pressed against each other; 
in other cases it will be found necessary to remove the bandages, expose 
the limb freely to the light arid air at least once or twice daily, and to 
rub it gently with the dry hand or with some moderately stimulating oil, 
so as to induce a more healthy condition of the soft parts, and encour- 
age the natural circulation. 

Moving the fragments freely upon each other, sufficient to determine 
a degree of excitement in the adjacent tissues, and upon the opposing 
surfaces of the bones, and then confining them during one or two weeks 
in firm and well-fitting splints, will sometimes succeed when other means 
have failed. 

1 Norris, loc. cit. 2 ibid., p. 29. 

George W. Callender, Brit. Med. Journ., Nov. 30, 1872. 



78 DELAYED AND NON-UNION OF BROKEN BONES. 

Indeed, I may say that by one or another of the simple methods now 
enumerated I have never failed, sooner or later, to effect consolidation 
in recent fractures ; and it has only been in fractures of at least four, 
six, or eight months' standing that I have been compelled to resort to 
more extreme measures. 

As a means of combining immobility with compression and healthful 
exercise, the " apparatus immobile," in many of its forms, is peculiarly 
adapted. White, of Manchester, employed a firm leather sheath for the 
thigh. H. H. Smith, of Philadelphia, 1 recommends a more complex 
artificial support, upon which the limb may be allowed to rest while in 
the act of progression. 2 With some surgeons, the object of allowing 
the patient to walk, in fractures of the thigh or leg, is chiefly to excite 
in the tissues adjacent to the seat of fracture some degree of inflamma- 
tory action ; but which, as the result in one of White's patients has suffi- 
ciently shown, may be carried too far, and even determine a suppuration. 

Dr. E. R. Hudson, artificial limb maker, of New York, has applied 
in similar cases, which have come under my observation, an apparatus 
of his own construction, made of willow, and secured in place by leather 
straps. In case the purpose of the apparatus is to encourage bony 
union, no motion is allowed at the knee-joint. 

Recently, also, Tiemann and Stollman have adapted to one of my 
patients successfully an apparatus of their own construction. This was 
a case of ununited fracture of the femur, of long standing, and in which 
I had succeeded by the use of Brainard's drills, the gimlet, and other 
operative procedures, in securing a very close and firm fibrous union. 
The fibrous band became finally converted into bone, after the lapse of 
a few months, while walking with crutches, the limb being supported by 
Mr. Tiemann's very ingenious apparatus. 

Blisters, mustard cataplasms, the tincture of iodine, 3 caustics, 4 etc., 
applied externally over the seat of fracture, can have no other effect 
than to increase moderately the congestion of the tissues, and in so far 
they may aid in the accomplishment of the bony union ; but in this 
respect they are inferior to the violent twistings, flexions, and rubbings 
of the broken ends of which we have already spoken. 

Electricity was first employed by Mr. Birch, of London, but Dr. 
Valentine Mott obtained no effect from it in two cases where he seems 
to have given it a fair trial. 5 Lente, of the New York Hospital, has 
furnished an account of three cases treated in that institution by elec- 
tricity in connection with acupuncturation ; the mode of using which 
was to pass a needle down to the periosteum on each side of the bone, 
and to attach the poles of the battery to these opposite points. Lente 
thinks that electricity employed in this way is much more efficient than 
when the poles are merely applied to the surface. He informs us also, 
that other cases than these now reported have been treated successfully 
in this hospital by means of electricity. 6 

1 See paper by H. H. Smith, Am. Jourri. Med. Sci., Jan. 1876. 

2 H. H. Smith, Am. Journ. Med. Sci., Jan. 1855. 

3 Hartshorne, Eclectic Rep., vol. iii. p. 114, 1813. 

4 Willoughby, Am. Journ. Med. Sci., Aug. 1834, p. 444. 

5 Mott, Med. and Surg. Rep., p. 21, p. 375. 

6 Lente, New York Journ. Med., Nov. 1850, p. 317. 



DELAYED AND NON-UNION OF BROKEN BONES. 



79 



Mercury will no doubt prove serviceable occasionally by virtue of its 
powers as an anti-syphilitic, but its beneficial influence in other cases is 
far from having been established. 

The seton is said to have been first suggested by Winslow, in 1787 ; 
but, what is of much more consequence, the credit of its first successful 
application and its general introduction into practice is due to Dr. Philip 
Syng Physick, of Philadelphia, by whom it was employed in 1802. 1 



Fig. 17. 



Fig. 18. 





Tiemann & Co.'s apparatus for ununited 
fracture of the femur. 



Physick's first case, after 28 years. 
(From Am. Journ. Med. Sci.) 



Physick used for his seton, generally, silk ribbon or French tape ; 
and this he introduced, by means of a long seton needle between the 
ends of the fragments. He recommended that the seton should remain 
in place four or five months, and longer if necessary, and it was his 
opinion that the failures were generally due to its being removed too 
early. At the present day, however, surgeons who employ the seton 
think it serves its purpose better when it remains in place but a few 
days, not longer, perhaps, than ten or fifteen, always taking care that 
it is removed before excessive suppuration is induced. It has been 
found especially valuable in fractures of the inferior maxilla, clavicle, 



1 Physick, Med. Repository of New York, vol. i., 1804. 



80 



DELAYED AND NON-UNION OF BROKEN BONES. 




and of the upper extremities ; but in the case of the femur it has so 
frequently failed, that Dr. Physick himself did not recommend its use. 

In case the seton cannot be passed directly between the opposing 
fragments, as recommended by Physick, we may adopt the practice 
suggested by Oppenheim, and carry two setons, one on each side, close 
to the bone. 

Somme', of Antwerp, preferred a loop of wire to the silk seton em- 
ployed by Physick. 1 Seerig passed a ligature around the ligamentous 
mass connecting the two fragments, and then pro- 
ceeded to tighten the ligature until it fell off*. 2 
Dr. Hulse, of the U. S. Navy, employed stimu- 
lating injections with success in a case of non- 
union, accompanied with an external and fistulous 
opening. 3 In 1848, DiefFenbach recommended that 
ivory pegs be introduced into holes previously 
made in the bone 4 by means of a gimlet or drill, 
and Mr. Stanley has succeeded once by this 
method. 5 Mr. Hill introduced the ivory pegs in 
a case of ununited fracture of the femur, pyaemia 
supervened, and the patient died. 6 

Malgaigne, in 1837, tried to introduce acupunc- 
ture needles between the ends of an united frac- 
ture, but, although he thrust the needle down to 
the bone thirty-six times, he was unable to make 
it pass once between the ends of the fragments- 7 
Wiesel succeeded better. In a case of ununited 
fracture of the ulna, of nine weeks' standing, 
having passed two needles between the fragments, at the end of six 
days, the needles being removed, consolidation rapidly ensued. 8 This 
practice does not differ essentially from the metallic hoop of Somme\ 
It is only a modification of the seton. 

Brainard, of Chicago, has attempted to show that setons of any kind, 
whether of wood, ivory, or metal, placed in contact with the bone, occa- 
sion absorption, caries, and necrosis, but that they never directly give 
rise to bony callus ; and that the occasional success of the seton, which 
success he believes to have been greatly exaggerated, has not resulted 
from any tendency to favor the formation of callus, but from the indura- 
tion and tenderness of the soft parts produced by it; circumstances 
which, by conducing to rest, indirectly favor the consolidation. 9 

In May, 1848, Miller,, of Edinburgh, reported five cases treated suc- 
cessfully by subcutaneous puncture. The operation consisted in passing 



Dieffenbach's drill for un- 
united fracture. 



1 Amer. Journ. Med. Sci., vol. vii. p. 497. 

2 Norris, loc. cit., p. 46. 

3 Hulse, Amer. Journ. Med. Sci., vol. xiii. p. 374. 

4 Malgaigne, trans, by Packard, op. cit., p. 258, note. 

5 Stanley, New York Journ. Med., Nov. 1854, p. 441, from Dublin Press. 

6 New York Med. Graz., July 4, 1868, from the London Lancet. 

7 Malgaigne, op. cit. 

8 Wiesel, Amer. Journ. Med. Sci., vol. xxxiv. p. 254. July, 1844. 

9 ' Brainard, Trans. Amer. Med. Assoc, vol. vii., 1854: Prize Essay. Report on 
Surgery to Illinois State Med. Soc, May, 1860. 



DELAYED AND NON-UNION OF BROKEN BONES. 81 

the point of a needle or small tenotomy bistoury down upon the ends of 
the bone, and freely irritating the surfaces at several points. 1 George 
F. Sandford, of Davenport, Iowa, has successfully imitated this practice 
in two cases. 2 

In 1850, Dr. William Detmold, of New York, performed the opera- 
tion of drilling or perforating the fragments in a case of ununited frac- 
ture of the tibia, employing for this purpose a large gimlet, He first 
bored two holes between the opposing fragments, and then, introducing 
the gimlet one and a half inch below the fracture, he penetrated the tibia 
upwards and inwards until he had traversed, also, the upper fragment to 
the extent of an inch. In three weeks the bone appeared firm, but from 
this time the patient was not seen. 3 

Brainard employs for this same purpose a strong metallic perforator, 
consisting of a handle, into which points of different sizes may be in- 
serted, and which have been hardened so as to penetrate the hardest 
bone or even ivory in every direction easily. The points are " some- 
what awl-shaped ; but more pointed in the middle rather than like a drill, 
which leaves chips." His manner of using this instrument is as follows: 
"In case of an oblique fracture, or one with overlapping, the skin is 
perforated with the instrument at such a point as to enable it to be car- 
ried through the ends of the fragments, to wound, their surfaces, and to 

Fig. 20. 




Brainard's perforator, reduced one-half. 

transfix whatever tissue may be placed between them. After having 
transfixed them in one direction, it is withdrawn from the bone, but not 
from the skin, its direction changed, and another perforation made, and 
this operation is repeated as often as may be desired." Dr. Brainard, 
who succeeded by this procedure in a number of cases of ununited frac- 
ture, thinks it better to commence in most cases with not more than two 
or three perforations, in order that the effect produced shall not be too 
severe. It is scarcely necessary to acid that, after the punctures have 
been made, the limb should be put completely at rest in appropriate 
splints, or in apparatus of some kind. 

Brainard's drills have been made latterly, not as originally directed 
by himself, with flattened points. Brainard directed that the point 
should be triangular ; the flattened points are liable to catch in rotation, 
and to break. This, indeed, happened in a case operated upon by Dr. 
Weir, at the New York Hospital, in consequence of which suppuration 
ensued, with erysipelas, and the patient died. 4 

Mr. Tiemann has made for me a bone-drill which is rotated by the move- 

■ _,_, 

' Miller, New York Journ. Med., July, 1848, p. 134. 

2 Sandford, Trans. Amer. Med. Assoc, vol. iii. p. 355, 1850. 

3 New York Med. Gazette, Oct. 12, 1850. 

4 Dr. Weir's Report to Path. Soc, Med. Record, Marcli 8, 1879. 



82 DELAYED AND NON-UNION OF BROKEN BONES. 

ment of a handle upon a rod or shaft composed of twisted wire, and which 
possesses the advantage of being worked with great facility and rapidity. 
Perforators of any size or shape may be fitted to the shaft at pleasure. 
In most cases I have found Brainard's drill a better instrument than my 
own. 

I have recently employed, as an addition to the surgical procedures 
above enumerated, common shawl pins, of steel, about four or six inches 
in length, having glass heads. Several of these are thrust between the 
ends of the bone, and are left in place seven or ten days ; to be inserted 
again from time to time as may seem desirable. 

Scraping or rasping the ends of the bones is a practice which dates 
from a very early period. Mr. Brodie scraped the ends of the bones, 
and then interposed a bit of lint. 1 Mayor, in 1828, contrived to intro- 
duce an iron, previously heated in boiling water, through a canula, and 
thus brought the heat to bear directly upon the ends of the fragments ; 
and, by repeating the application several times, a cure was effected. 2 

Resection of the ends of the bones, first brought into notice by White, 
of Manchester, in 1760, 3 and opposed by Brodie 4 as dangerous, and by 
Malgaigne regarded as generally useless or unnecessary, has still been 
practised a great number of times, with more or less success. It is espe- 
cially applicable to superficial bones, and in cases where the bones over- 
lap. Its value is now sufficiently demonstrated, except perhaps in the 
case of the femur. 

Roux practised resection in one instance, and then managed to engage 
the point of one of the fragments in the medullary canal of the other. 5 
I have succeeded in doing the same. 

White, of Manchester, Henry Cline, of London, Hewson, Barton, and 
Norris, of Philadelphia, have applied caustics directly to the ends of the 
fragments, after having exposed them by a free incision. 6 Petit applied 
the actual cautery. 7 

Tying the fragments together by means of metallic ligatures after a 
recent fracture, is as old as the days of Hippocrates ; but in 1805 Horeau 
adopted the same procedure in a case of ununited fracture ; 8 since which 
date it has been practised successfully by many surgeons. My own ex- 
perience confirms the value of the method, especially when the fragments 
overlap. 

E. S. Gaillard, of Louisville, Ky., proposes to secure the fragments 
in place by means of a metallic pin. The instrument which he employs 
is composed of a steel shaft with a handle, a silver sheath, and a brass 
nut. For a broken femur, the shaft is six inches long, its lower ex- 
tremity being constructed like a gimlet, while two and a half inches of 
its upper extremity are cut for a male screw, being intended to carry 
the brass nut. The sheath is three inches long. 

Through an incision made over the seat of fracture, the sheath, de- 
tached from the shaft, is carried down to the bone. The shaft is then 
passed through the sheath, and made to penetrate and transfix the two 

1 Brodie, Lond. Med. Graz., July, 1834. 2 Norris, loc. cit., p. 48. 

8 Diet, de M6d., vol. xxiii. p. 503. 

4 Brodie, New York Journ., vol. viii. 1st ser., p. 133. 

5 Norris, loc. cit., p. 49. 6 Ibid. 7 Ibid. 8 Ibid. 



DELAYED AND NON-UNION OF BROKEN BONES. 83 

fragments ; as soon as this is accomplished, the nut is turned down 
firmly upon the top of the sheath, and apposition of the fragments is thus 
secured. The whole instrument is permitted to remain until bony union 
is effected. 1 

Fig. 21. 




Gaillard's instrument for ununited fractures. 

Fitzgerald, of Melbourne, has practised successfully the injection of 
five to ten minims of glacial acetic acid between the fragments. It 
causes at first a sharp pain, and he thinks it accomplishes its beneficial 
results by causing a resolution and absorption of the interposed fibrinous 
cartilaginous materials and encouraging the substitution of bone. 2 

Finally, having thus brought rapidly before us all of the various 
modes of treatment which have been suggested and practised for non- 
union of broken bones, we are prepared to affirm the following conclu- 
sions, or summary of what has been our own practice, and of what we 
believe ought to be the general course of procedure in these cases : — 

First. Improve the condition of the general system. 

Second. Remove as far as possible the local impediments, such as a 
separation of the fragments, local paralysis, local scurvy resulting from 
long exclusion from light and air, congestions, etc. 

Third. Increase the action of the tissues immediately adjacent to the 
fracture, upon which tissues, rather than upon the bone, as Malgaigne 
thinks, the formation of callus depends : a theory which, as applied to 
old and ununited fractures, we are not prepared to deny. This may be 
accomplished by frictions, and violent flexions of the limb at the seat of 
fracture ; possibly in some measure by the application of vesicants or of 
other stimulants to the skin itself. 

Fourth. Employ again compression and rest for a period of from two 
to four or eight weeks. 

Fifth. Resort to the method recommended by Brainard, or to some 
of its modifications, to interfragmentary injections, etc. 

Sixth. If in the lower extremity, allow the patient to walk about with 
the fragments well supported. 

Seventh. If the fracture is not in the femur, and as an extreme meas- 
ure, employ the seton, or resection. 

Where these measures have failed, after a fair trial, we should cease 
to hope for success from operative measures, and hereafter rely only 
upon retentive apparatus, under the continued use of which consolidation 
is sometimes effected. 

1 E. S. Gaillard, New York Journ. Med., Nov. 1865. 

2 Boston Med. and Surg. Journ., Aug. 15, 1878, from Medical Press and Circular. 



84 BENDING, PARTIAL FRACTURES, AND FISSURES. 

More precise rules of procedure will be given hereafter in connection 
with the various fractures. 

Dr. Frank Muhlenberg, of Philadelphia, has made a very valuable 
contribution to this subject in a collection of cases drawn from the 
medical journals, and published in a tabular form by Dr. Agnew in his 
treatise on surgery. The student will do well to consult this table, 
which occupies fifty-seven pages of Dr. Agnew's excellent book. In a 
summary of the whole number, 656 cases, it is stated that 565 were 
males, and 91 females. The youngest was 13 years old and the oldest 
70, the largest number being within 28 and 40 years. In 61 the frac- 
tures had existed less than three months ; the shortest period being 
three weeks, and the longest ten years. The whole number cured by 
the various plans of treatment was 385 ; of the remaining 271, 43 were 
relieved — that is, the amount of motion between the fragments was less- 
ened — in 204 no benefit was derived from the operation, 19 proved 
fatal, and in 5 the result is not known. 1 

It might have been well to have noted what proportion were cured 
after five months, after six months, and after one year, since I would 
not regard a case as properly one of non-union until after the fifth month. 

It is also scarcely necessary to say that unsuccessful, and especially 
fatal, cases are not so likely to find their way into the journals as suc- 
cessful cases, so that it must be assumed that the actual proportion of 
failures is greater than these tables represent. 



CHAPTEE VIII. 

INCOMPLETE FKACTURES. . 

BENDING, PARTIAL FRACTURES, AND FISSURES OF THE LONG BONES. 

§ 1. Bending of the Long Bones. 

Strictly speaking, no bone can be much bent without being also 
more or less broken, and that whether it immediately and spontaneously 
resumes its position or not ; for, if the bending and straightening of the 
bone be repeated a sufficient number of times, the yielding of the fibres 
will become apparent, and at length the separation will be complete. 
The first of this series of flexions was quite as much responsible for this 
result as the last, and, no doubt, performed its share in the production 
of the complete fracture. 

There could be no impropriety, therefore, in speaking of a bending 
of the bones as a variety of incomplete fractures, as I have done in the 
first section of my " Report on Deformities after Fractures," made to 
the American Medical Association in 1855. 2 

1 Principles and Practice of Surgery, by D. Hayes Agnew, M.D., LL.D., Prof, of 
Surg, in Univ. of Pa., vol. i. pp. 752-808. 

2 Op. cit., pp. 421-422. 



BENDING OF THE LONG BONES. 85 

They have been called, not inappropriately, interperiosteal fractures, 
since in these cases the periosteum is not broken ; M. Blandin thinks 
that the outer and semicartilaginous laminae of the bone also do not 
break, while the deeper laminae suffer an actual disruption. 1 But it is 
quite as probable that in a majority of cases the true pathological con- 
dition is a compression of the bony fibres upon one side, with a corre- 
sponding expansion upon the opposite side, with only a slight interstitial 
fracture, too trivial to be easily recognized even in the dissection. 
Sometimes, as I have several times observed in my experiments on the 
bones of chickens, when the bones are small, and the bending is near 
the centre of the shaft, the whole of the laminae on the side of the retir- 
ing angle produced by the bending are doubled in, or indented toward 
the hollow of the bone, so that the fibres on the side of the salient angle 
are not even stretched, and much less broken. In- such cases, the inter- 
stitial disruption, if it exists at all, and I think it does, first takes place 
in the deeper layers of the retiring angle. 

I might, therefore, feel justified in continuing to call these cases par- 
tial fractures, or, perhaps, interstitial fractures, but I believe that the 
whole subject will be rendered more intelligible if I call them simply 
bending of the bones, as distinguished from those other and more pal- 
pably partial fractures of which I shall speak presently. 

1. Bending ivith an immediate and spontaneous restoration of the 
bone to its original form. — The possibility of this accident, to which, 
however, surgical writers have hitherto made no distinct allusion, is ren- 
dered certain by the following experiments : — 

Experiment 1. — July 16, 1857. I bent the tibia of a Shanghai 
chicken, four weeks old, at about the middle of the bone. It was bent 
to an angle of quite twenty-five degrees, but it was not felt or heard to 
break. It immediately and spontaneously resumed the straight position. 

July 18, two days after the bending, I dissected the limb, and found 
no trace of the injury, either within or without the bone, unless I ex- 
cept a very minute blood-clot in the centre of the shaft. 

Experiment 2. — I bent the leg of a chicken, four weeks old, at the 
same point and to the same degree. It immediately resumed the straight 
position. 

Dissection after two days. Nothing abnormal except a small blood- 
clot in the centre of the bone, and a slight disorganization of the medulla. 

Experiments 3 and 4. — Bent both legs of a chicken, four weeks old, 
at the same point and in the same manner. They immediately resumed 
their positions. 

Dissection after two days. No lesions or morbid appearances which 
I could detect. 

Experiments 5 and 6. — Bent both wings of a chicken four weeks old, 
bent the right wing to an angle of thirty-five degrees. I did not feel 
them break. Both resumed their positions spontaneously. 

Dissection after two days. No lesions or other morbid appearances. 

Experiment 7. — July 16, 1857, 1 bent the leg of a Shanghai chicken, 

1 Markham's Obs. on the Surg. Practice of Paris, London Med. Chir. Rev., vol. 
xxxiv. p. 473, 1841. 



86 BENDING, PARTIAL FRACTURES, AND FISSURES. 

five weeks old, below the knee and about the middle of the bone. It 
was bent to an angle of about twenty-five degrees, but the bone was not 
felt or heard to break. It immediately and spontaneously resumed the 
straight position. 

July 20, four days after the bending, I dissected the leg, but could 
not discover any trace of the injury, except that there was a very mi- 
nute ossific deposit in the centre of the bone at the point at which I 
suppose it to have been bent. 

Experiment 8. — July 16, 1857, I bent the right leg of a Shanghai 
chicken, five weeks old, at the same point as in the first experiment, and 
to the same extent. The bone did not seem to break, but it immediately 
and spontaneously resumed the straight position. 

Dissection after four days. Nothing appeared to indicate the seat of 
the bending except a small clot of blood in the centre of the shaft. 

Experiment 9. — Bent the leg of a chicken, six weeks old, in the same 
manner and to the same degree as in the other examples. It resumed 
its position spontaneously. 

Dissection after ten days. No evidence of injury of any kind ; the 
bone being sound and straight. 

These experiments were made in connection with others to which more 
especial reference will hereafter be made. They are selected, and con- 
stitute the whole number of those in which I did not feel the bone break 
or crack under my fingers. In every instance the bone sprung back 
immediately and spontaneously to its natural form. In no instance could 
I afterwards discover any trace of lesion or sign indicating the point at 
which the bone had been bent before dissection, nor did dissection itself 
disclose anything but the most inconsiderable marks, and that in but 
three examples. 

I infer, therefore, not forgetting the caution with which the conclu- 
sions from all such experiments ought to be applied to similar accidents 
upon the human skeleton, that whenever the bones of healthy infants 
have been slightly bent and not broken, they will, probably, in most 
cases, unless prevented by causes foreign to the bones themselves, spon- 
taneously and immediately resume their position, and that no sign will 
remain to indicate that a bending has occurred. The accident will not 
be recognized, and, as a further inference, this bending does not belong 
to that class of cases of which I shall next speak. 

2. Bending without immediate and spontaneous restoration of the 
hone to its original form. — " Dethleef, believing that he had broken the 
two bones of the leg of a dog, found the fibula bent without a fracture. 
Similar results were obtained by Duhamel upon a lamb ; by Troja upon 
a pigeon ; and I have myself twice succeeded in bending the fibula while 
breaking the tibia. The possibility of simple curvature is then not con- 
testable" (the writer means to say that the possibility of a simple cur- 
vature remaining permanently bent is not contestable), "but we must 
observe that they have never been obtained except upon young animals, 
and that they have been unable to maintain themselves permanently 
except through the aid of a fracture and displacement of a neighboring 
bone ; and there is a wide difference between these and those pretended 
curvatures which some believe they have seen in man, in which the 



BENDING OF THE LONG BONES. 



Fig. 22. 



curved bone maintains itself, and resists perfect reduction until the frac- 
ture is complete." 1 

In this single paragraph Malgaigne seems to have given a fair summary 
of the testimony upon this point. With the exception of these and a 
few other similar examples, some of which I think 1 have observed my- 
self, where one of the bones of the forearm has been broken and the 
other bent, I know of no well-attested cases of a permanent bending : 
using the term bending in a sense distinguished from a partial fracture. 

If, in numerous cases mentioned by surgical writers, there has seemed 
to be probable evidence that the permanent bending was unaccompanied 
with fracture, there has always been wanting, so far as I know, the posi- 
tive evidence of dissection. The example of partial fracture mentioned 
by Fergusson, and represented by a drawing, is described as having 
also, " toward the lower extremity, a slight indentation and curve." 2 
This was the radius of a child ; but how long the child survived the 
accident, and what w r as the condition of the ulna, we are 
not informed. The observations made by Jurine, of 
Geneva, in Switzerland, 3 by Barton 4 and Norris, 5 of 
Philadelphia, all fail to furnish any such conclusive evi- 
dence of the correctness of their own views. Norris 
says that " Thierry, of Bordeaux, Martin, and Chevalier, 
had all met with and published cases of this kind prior 
to the appearance of Jurine's paper (in 1810), the former 
of whom asserts that Haller, in experimenting upon the 
subject, had been able satisfactorily to produce the same 
accident in young animals." For myself, I cannot say 
how much confidence we ought to place in these asser- 
tions of Thierry, Martin, and Chevalier, having never 
seen the papers referred to ; but since Dr. Norris has 
neglected to inform us whether any dissections were ever 
made, we shall not be expected to regard their testimony 
as conclusive. 

With the qualifications now made, Gibson was more 
nearly right when he said, " Dupuytren and Dr. John 
Rhea Barton have each furnished accounts of bent bones. There are 
no such injuries, however, in my opinion ; such cases being, in reality, 
partial fractures from which deformities result upon the same principle 
that a piece of tough wood, like oak or hickory, if broken half through, 
may be inclined to one side and shortened, although still held together 
by interlocking of fibres. Many specimens in my cabinet, and in the 
Wistar Museum, attest the accuracy of this assertion." 6 

In my own experiments upon the chicken, the bones uniformly re- 
sumed their original position as soon as the restraining force was re- 
moved, unless a fracture occurred, and this notwithstanding the bones 
were bent quite abruptly and to an angle of twenty-five degrees. Cer- 




Case mentioned by 
Fergusson. 



1 Traite des Frac, etc., par L. F. Malgaigne, torn. i. p. 48. 

2 Practical Surgery, by William Fergusson, 4th Am. ed., p. 208. 

3 Journ. de Corvisart et Boyer, torn. xx. p. 278, etc. 

4 Phila. Med. Recorder, 1821. 5 phila. Med. Journ., vol. xxix. p. 233, 1842. 
6 Institutes and Practice of Surgery, by Wm. Gibson, Phila., 1841, vol. i. p. 254. 



88 BENDING, PARTIAL FRACTURES, AND FISSURES. 

tainly, if the bones of children may be bent during life and be made to 
retain this position without a fracture, then the same thing might be 
done upon the bones of children recently dead, and, by successful ex- 
periments, this long-agitated question might be easily and forever put to 
rest. 

It will be understood that our observations are confined to the long; 
bones. That the flat bones, and especially the bones of the cranium, in 
childhood, may be indented by blows, and remain in this condition, is 
undeniable. Scultetus says he had seen " the skull pressed down in chil- 
dren, without a fracture, so that those who touch or look upon it can per- 
ceive a small pit," 1 and it has been mentioned by many writers since, 
and perhaps before his day. I have myself published two examples of 
it in the second volume of the Buffalo Medical Journal? and since the 
date of that publication I have met with others. 

§ 2. Partial Fracture of the Long Bones. 

1. Partial Fracture with Immediate and Spontaneous Restoration of 
the Bone to its Original Form. — No writer seems to have given any 
special attention to the form of fracture now under consideration, al- 
though its existence appears to have been occasionally recognized. In 
the case reported by Camper, in 1765, of a partial fracture of the tibia, 
the bone had regained its natural form, but whether immediately after 
the accident occurred, or at a later period, I am not able to learn. 3 
Jurine, Gulliver, and others, have noticed a gradual straightening of 
the bone after a partial fracture, so that its complete restoration has 
been accomplished after several weeks or months ; but this, although 
partly due to the same cause which produces occasionally an immediate 
restoration, namely, its elasticity, is in part also due to other causes, and 
will be more properly considered under the next division of partial 
fractures. 

Says Malgaigne : " Finally, at other times the fracture takes place 
without opening and without curvature ; the only sign which one can 
recognize is a yielding of the bone under the pressure of the finger at 
the point of fracture ; yet upon the living subject we may see the same 
symptom pertain to complete and simple fractures without displacement." 4 

In the following report of one of M. Blandin's clinics the accident is 
described a little more distinctly : " In some cases of fracture of the 
clavicle occurring about the middle of the bone in young subjects, dis- 
placement of the fragments does not immediately take place, thus giving 
rise to a risk of an error in diagnosis, by which the ultimata probability 
of a cure is diminished. A lad seventeen years of age was recently 
admitted into the H6bel Dieu, under the care of M. Blandin, having, a 
few days previously, fallen upon one of his comrades while playing with 
him, when he instantly experienced pain and a cracking sensation about 
the middle of the left clavicle, where there soon formed a tumor, which, 

1 The Chirurgeon's Storehouse, by Johannes Scultetus, 1674, p. 126. 

2 Op. cit., p 347, 1846, Cases 1 and 2. 

3 Essays and Obs. Phys. and Lit. of Soc. of Edinburgh, vol. iii. p. 527. 

4 Op. cit., torn. i. p. 50. 



PARTIAL FRACTURE OF THE LONG BONES. 89 

increasing, induced him to enter the hospital. On examination, the 
swelling was found to occupy the middle of the clavicle ; it was about 
as large as half a hen's egg, ovoid in shape, well circumscribed, color- 
less, and hard, but sensible to pressure. There was not any deformity 
of the shoulder, nor any abnormal modification of the axis of the bone, 
to indicate the existence of a fracture ; and although the different move- 
ments of the arm caused pain in the shoulder, yet they could be made 
without much difficulty. 

" The symptoms in this case would lead to the belief that it was a 
case of simple periostitis, caused by external violence ; but M. Blandin 
at once decided that there existed a fracture of the bone, having seen 
a similar case previously at the hospital Beaujon, where the tumor was 
treated as traumatic periostitis, the patient merely carrying his arm in 
a sling, until, by a sudden movement of the limb, displacement of the 
fragments was produced, and clearly demonstrated the existence of a 
fracture. A second case occurring soon afterward, M. Blandin profited 
by the experience gained from the preceding, and by moving the frag- 
ments of the broken clavicle on each other, obtained motion and crepi- 
tus. Still these indications were not so clear, that M. Marjolin could 
diagnosticate a fracture ; he was of opinion that the case was one of ex- 
ostosis, probably syphilitic, and the crepitus, he believed, depended on 
an erosion of the osseous surface. In consequence, the patient was left 
to himself, until a movement of the arm gave proof of the fracture by 
the displacement of the broken portions of the bones. 

"Two other cases occurring in young subjects have been admitted 
since in the Hotel Dieu, under the care of M. Blandin, one of whom 
was purposely left without surgical assistance, while Desault's bandage 
was applied to the other. The former soon showed evidence of consecu- 
tive displacement; the latter was cured without any deformity following. 

"The surgeon may diagnose a fracture, without displacement of the 
middle portion of the clavicle, when a circumscribed tumor forms in that 
part of young subjects, consecutive on a fall on the shoulder, and motion 
of the fragments, with crepitus, can be detected, there not being any 
syphilitic taint in the constitution." 1 

The following examples, which have come under my own observa- 
tion, will illustrate more completely the usual history and symptoms 
of these cases : — 

A. B., aged three years, fell from the sofa upon the floor, striking, 
it is thought, on her right shoulder. Two days after this, she fell 
again, and then for the first time Mr. B. noticed the deformity. She 
was brought to me three days after the second fall. There existed 
then a round, smooth projection at the outer end of the middle third 
of the clavicle. It felt hard, like bone. The line of the clavicle was 
not changed. I advised a handkerchief sling, simply to steady and 
support the arm. Seven months after the accident, she fell sick and 
died. The projection continued at the time of death, only slightly 
diminished. 

1 Am. Journ. Med. Sci., vol. xxxi. p. 473, from Journ. de Med. et Chirurg. Prat., 
July, 1842. 
7 



90 BENDING, PARTIAL FRACTURES, AND FISSURES. 

II. S., aged six years, was thrown from a horse, partially breaking 
his left clavicle, near its middle. Dr. Sprague, of Buffalo, was em- 
ployed. The projection in front was for several days very apparent, and 
was examined by myself at Dr. Sprague's request. The bone did not 
seem to be out of line. Five years after the accident, I examined the 
lad, and could not find any trace of the original injury. 

September 25, 1855, Mrs. T. C. brought to me her infant child, then 
but two weeks old. Upon the left clavicle, at a point a little nearer 
the acromion process than the sternum, was an oblong swelling, three- 
quarters of an inch in length, smooth and hard like callus ; the skin 
was not reddened, nor tender. There was no motion or crepitus, and 
the line of the axis of the bone was perfect. The mother, who had 
been put to bed by a midwife, thinks the injury occurred in the act of 
birth, although she did not notice the swelling until a week after. 

October 20. Nearly one month later, I found no change in the con- 
dition of the bone ; the hard lump remained, but it was still entirely 
free from tenderness. I have not seen the child since. 

An infant boy, three years old, fell, August 12, 1857, from the 
hands of the nurse. The child cried, but the point of injury was not 
detected until the third or fourth day, although the mother examined 
the shoulders and neck carefully at the time. She is quite certain 
that if any swelling or discoloration had been present, she would have 
seen it then, or on the subsequent days, while washing and dressing the 
child. When first seen it was very distinct, but not so large as at 
present. 

August 19. The child was brought to me. A little to the sternal 
side of the middle of the right clavicle there was an oblong node-like 
swelling, of the size of the half of a pigeon's egg, hard, smooth, and 
feeling like bone ; there was no discoloration or swelling of the integu- 
ments ; no crepitus or motion ; the line of the clavicle seemed nearly or 
quite unchanged. 

I have not noticed this variety of accident in any other bone except 
the clavicle, yet it is not improbable that it happens occasionally, and 
perhaps quite as often, in other long bones, but that its existence is not 
elsewhere so easily recognized. 

Of one hundred and fifty-seven fractures of the clavicle recorded by 
me, thirty-four were partial fractures ; and of these at least eleven were 
spontaneously and immediately restored to their natural axes. 

In explanation of the fact that hospital surgeons have not observed 
so large a proportion of partial fractures of the clavicle, it must be stated 
that most of these cases of partial fracture were drawn from private 
practice. Accidents of this class may be often met with in private 
practice and in dispensaries, but they are seldom found in hospitals. 

Experiment. — In fourteen experiments upon the bones of chickens, 
a partial fracture, with immediate and spontaneous restoration, has 
occurred but once. In nine of these cases the bones were only bent, 
and in five they were partially broken ; an immediate restoration has 
occurred, therefore, in one case out of five of partial fractures ; while in 
my recorded examples of partial fracture of the clavicle it has been 



PARTIAL FRACTURE OF THE LONG BONES. 91 

noticed about once in every four or five cases. The following is the 
experiment to which I have referred : — 

I produced a partial fracture of the tibia in a chicken six weeks old. 
The fracture was near the middle of the bone. It was felt to break 
under my finger ; but on removing the pressure, it immediately and 
spontaneously resumed the straight position. 

The limb was dissected on the tenth day. The line of the axis of the 
bone was perfect ; but on the fractured side was a node-like enlarge- 
ment, sufficient to be distinctly felt and seen before the soft parts were 
removed. 

Pathology. — In no case, except in my single experiment upon the 
bone of a chicken, has the actual condition been determined by dis- 
section, and if any question has existed heretofore as to the possibility 
of an immediate and spontaneous restoration after a partial fracture, 
this experiment ought to decide it in the affirmative ; but then the first 
nine experiments already quoted have shown that a mere bending with 
immediate restoration leaves no such traces or signs as have been de- 
scribed as following these accidents. We have, therefore, the negative 
argument that, since a bending with restoration leaves no signs, these 
examples, reported by myself and others as having occurred, and as 
having been followed by a node-like swelling, etc., must have been 
partial fractures. Moreover, in one of the cases of immediate restora- 
tion reported by Blandin, there was a feeble crepitus : and in another 
the subsequent displacement proved the correctness of his diagnosis. 
The same has been noticed by myself in several examples. 

We conclude, then, that these are examples of partial fracture, but 
that the number of bony fibres which have given way are too incon- 
siderable, as compared with those not broken, to affect materially the 
elasticity of the bone. 

Diagnosis. — The diagnosis will depend somewhat upon the history of 
the accident as well as upon the present symptoms. In no instance, 
where I could ascertain the cause, have I known an incomplete fracture 
of this variety produced by any other than an indirect blow ; and where 
the clavicle has been the seat of the fracture, the counter-blow has been 
received upon the end of the shoulder. The fact possesses, therefore, equal 
significance in its relation to either of the varieties of partial fracture ; 
but in the case of a partial fracture with a permanent curvature, the 
diagnosis would be complete without the history, while in this case it 
might not be, and a knowledge of the manner in which the accident 
occurred would, therefore be of great importance. 

The signs, then, after a knowledge of the fact that a blow has been 
received upon the shoulder, are a node-like swelling upon the anterior 
or upper face of the clavicle, generally in its middle third, this swelling 
being hard, smooth, oblong ; the skin only slightly or not at all swollen 
or tender, and in no way discolored, as it would have been had the 
swelling upon the bone been the result of a direct blow ; and the line of 
the axis of the bone being unchanged. I have occasionally detected 
motion and crepitus at the point of injury, and we have seen that Blandin 
was able to detect both in one instance ; but it has never occurred to 
me to see the swelling upon the bone until two or three days after the 



92 



BENDING, PARTIAL FRACTURES, AND FISSURES 



injury was received. We are not very likely, therefore, to recognize 
this accident immediately after its occurrence. 

Treatment. — In the case of the clavicle, neither bandages, slings, 
compresses, nor lotions, can be of much service. Yet no harm can arise 
from employing a simple sling and roller to confine the arm ; and it is 
always proper to enjoin some degree of care in using the arm of the 
injured side. The consolidation will be speedily accomplished, and 
after a time the ensheathing callus will wholly disappear. 

If a similar accident should occur in any other of the long bones, as 
retentive and precautionary means, splints ought to be applied, at least 
for a few days. 

2. Partial Fracture without immediate and spontaneous restoration 
of the bone to its natural form. — The causes of this accident are the 
same with those which produce simple bending, or partial fracture with 
immediate and spontaneous restoration, from which latter they differ 
probably in the greater extent of the bony lesion. Perhaps, also, they 
differ sometimes in the peculiar form and degree of the denticulation at 
the seat of the fracture ; in consequence of which an antagonism of the 
fibres takes place, preventing a restoration of the bone to its original form. 

Very few surgeons have spoken of partial fractures in the clavicle, 
while Jurine, Syme, Liston, Miller, Norris, and many others, have 



Fig. 23. 



Fig. 24. 




Partial fracture of the clavicle without spontaneous restoration. From 
nature ; taken three weeks after the accident. 



declared that it is much more frequent in the bones 
of the forearm than elsewhere. This does not agree 
with my experience, according to which it occurs 
oftener in the clavicle than in the forearm ; a dis- 
crepancy which I cannot very well explain, except 
by supposing that, in the case of the clavicle, the 
accident has either been overlooked entirely or mis- 
apprehended. Blandin, who, we have seen, has re- 
ported five cases of partial fracture of the clavicle 
with rmmediate restoration, states distinctly that in two of these cases 
distinguished surgeons of Hopital Beaujon and Hotel Dieu failed to 
recognize it. 



Partial fracture with 
out restoration of thi 
hone to its natural form 



PARTIAL FRACTURE OF THE LONG BONES. 93 

Says Turner : " The next I shall descend to is that of the clavicle or 
collar-bone, which I have found the most frequently overlooked, I think, 
of any other, till it has been sometimes too late to remedy, especially 
among the children of poor people ; for, though they find these little 
ones to wince, scream, or cry, upon the taking off or putting on their 
clothes, yet, seeing that they suffer the handling of their wrists and 
arms, though it be with pain, they suspect only some sprain or wrench, 
that will go away of itself, without regarding anything further or look- 
ing out for help ; whereas, this fracture discovers itself as easily as 
most others. For not only the eye, in examining or taking a view of 
the part, may plainly perceive a bunching out or protuberance of the 
bones when the neck is bared for that purpose, with a sinking down in 
the middle or on one side thereof, which will be still more obvious on 
comparing it with its fellow on the other side ; but when it is more ob- 
scure, and the bone, as it were, cracked only — a semi-fracture, as we 
say — yet, by pressing hard upon the part, from one extremity to the 
other, you will find your patient crying out when you come upon the 
place ; and by your fingers, so examining, sometimes perceive a sinking 
further down, with a crackling of the bone itself." 1 

Erichsen, who regards all of these cases as mere bendings of the bones, 
remarks that it " most commonly occurs in the long bones, especially the 
clavicle, the radius, and the femur." 2 He says, moreover, " Fracture 
of the clavicle in infants not unfrequently occurs, and is apt to be over- 
looked. The child cries and suffers pain whenever the arm is moved. 
On examination, an irregularity, with some protuberance, will be felt 
about the centre of the bone." 3 The reader will not fail to recognize 
in these symptoms the incomplete fracture of which we are now speak- 
ing, although Erichsen evidently believes them to be examples of com- 
plete fracture. 

In addition to this testimony as to the frequency of these fractures in 
the clavicle, I will only mention that Johnson, in his review of Mark- 
ham's Observations on the Surgical Practice of Paris, says that " many 
surgeons have noticed the incomplete fracture of the clavicle, as of other 
bones, which takes place in the young." 4 

Pathology. — The following experiment will assist in the elucidation 
of this part of our subject: — 

Experiment. — I bent the leg of a chicken five weeks old. It cracked 
under my fingers, and remained bent. Having waited a few seconds, 
and finding that it was not restored to position, I pressed upon it and 
made it straight. The chicken walked off without any limp. 

On the fourth day, before dissection, the bone looked as if it was still 
bent ; but on removing the soft parts, the line of the axis of the bone 
was found to be straight. The areolar tissue under the skin was infil- 
trated with lymph, which was most abundant near the fracture, and 
gradually diminished toward each extremity of the limb. This effusion 
was confined almost entirely to the front of the limb, or to that side which 

1 Art of Surgery, by Daniel Turner, London, 1742, vol. ii. p. 255. 

2 Science and Art of Surgery, Phila. ed., 1854, p. 180. 

3 Op. cit., p. 205. 4 Lond. Med.-Chir. Rev., vol. xxxiv. p. 474, 1841. 



94 BENDING, PARTIAL FRACTURES, AND FISSURES 



Fig. 25. 



had been broken, and constituted the greater part of the enlargement, 
which I had noticed before the dissection was commenced, and which 
then felt like bone. 

On the front of the bone, also, underneath the periosteum, there was 
a loose, honeycomb deposit of ensheathing callus, about one line in thick- 
ness, and extending upwards and downwards about half an inch. This 
callus surrounded the bone in three-fourths of its circumference ; but 
there was no callus on its posterior surface. It was also deficient exactly 
along the line of fracture, in front and on the sides, in consequence of 
which an oblique groove remained, indicating the seat of the fracture. 

In three other experiments, the particulars of which are detailed in 
the earlier editions of this book, similar results were obtained. 

So early as the year 1673, a dissection made by Glaser demonstrated 
incontestably the existence of partial fractures in the shaft, and in the 
direction of the diameter of long bones. 1 Camper, in 
1765, again described a specimen which he had seen ; 2 
and Bonn, in 1783, added a third positive observa- 
tion. 3 

M. Gimele is, therefore, in error when he ascribes 
to Campaignac the credit of having first proven by 
dissection their existence, in a paper communicated 
to the Academy of Medicine at Paris, in 1826. Cam- 
paignac, however, seems to have been the first who 
described very particularly the condition of this frac- 
ture. He has recorded the history and dissection 
of two cases, one of which occurred in the fibula, 
and one in the tibia. The first of these cases was a 
girl twelve years old, who survived the accident just 
eight weeks. The fracture had occurred near the 
middle of the bone, and upon the interior and internal 
side ; in which direction, resting against the tibia, the 
bone was found inclined. " The bony fibres had been 
broken at different lengths, almost exactly like what 
takes place in the branch of a tree which has been 
partially broken ; and, as we see sometimes in this 
latter case, the bundles of splintered bony fibres abutted 
upon themselves, and did not take their places w T hen 
we endeavored to restore them ; so the abnormal angle 
which the fibula represented could not be effaced, the 
ends of the divided fasciculi not restoring themselves 
to their respective places. This disposition might be 
especially seen toward the anterior part of the internal 
face, where a packet of fibres, coming from below, was 
braced against the upper lip of the division, which it thus held open. 
This opening at first made me think that the fragments could not have 
been well consolidated ; but I assured myself that it was, and the fact 



Partial fracture ; after 
union is consummated. 



1 Malgaigne, op. cit., p. 44, from Th. Boneti Sepulchretum, 1700, torn. iii. p. 424. 

2 Essays and Obs. Phys. and Lit. of Soc. of Edinburgh, 1771, vol. iii. p. 537. 

3 Malgaigne, op. cit., p. 44, from Descript. Thes. Ossium Morb. Hoviani, 17S3. 



PARTIAL FRACTURE OF THE LONG BONES. 95 

was subsequently confirmed by the Academy of Medicine ; all the points 
which were in contact were found intimately united." 1 

Diagnosis. — The diagnosis is not difficult. The distortion indicates 
sufficiently the existence of a fracture, while the complete absence of 
crepitus in nearly all cases, and of either overlapping or lateral displace- 
ment, must generally, especially where the accident has occurred in a 
child, sufficiently indicate that the fracture is incomplete. It will assist 
the diagnosis, also, to notice that these accidents are almost confined to 
the middle third of the long bones ; and they are produced usually by 
a bending of the bones, the forces operating upon the extremities, and 
not directly upon the point which is broken. 

In complete fractures, also, preternatural mobility is so constant a sign 
as to be regarded as diagnostic, while here there is almost always a great 
degree of immobility at the seat of fracture. The angle made by the 
projecting extremities is usually rather gentle and smooth ; at other times 
it is abrupt, indicating a greater amount of fracture, or that the outer 
fibres are broken more irregularly. The power of using the limb is 
generally sensibly impaired, but not completely lost. 

Treatment. — Jurine, Alurat, Campaignac, Gulliver, Malgaigne, with 
some others, have noticed the fact that it is often difficult, and some- 
times quite impossible, to restore these bones to position ; a circumstance 
which they have justly ascribed to that condition of the fragments de- 
scribed by Campaignac. The broken extremities of the fasciculi become 
braced against each other, and effectually resist all efforts to straighten 
the bone ; unless, indeed, so much force is used as to render the frac- 
ture complete: a result which, if it should chance to happen, need not 
occasion any alarm, since, while it enables us at once to restore the bone 
to line, it does not much increase the danger of lateral displacement and 
overlapping. That the fracture has become complete we may know by 
a sudden sensation of cracking, by the increased mobility, and by the 
crepitus, which is now easily developed. 

But we need not, on the other hand, be overanxious to straighten the 
bone completely, since experience has shown that after the lapse of a 
few weeks or months the natural form is usually restored spontaneously. 
I am not now T speaking of those cases in which the restoration occurs 
immediately, where it is probable that the splintered fibres offer no re- 
sistance to the restoration ; but only of those in which the bone straightens 
so gradually as to induce a belief that the broken ends are the cause of 
the resistance. To this variety of accident belong cases one, five, six, 
seven, and eight, published in my Report on Deformities after Frac- 
tures ; 2 in one of which the natural axis was resumed in less than four 
weeks. In a case mentioned by Gulliver, it required about the same 
time to render the bones of the forearm perfectly straight; and in one 
case mentioned by Jurine, at the end of six months it was " difficult to 
say which arm had been broken, and at the end of one year it was im- 
possible." 

1 Des Fractures Incompletes et des Fractures Longitudinales des Os des Merubres ; 
par J. A. J. Campaignac. Paris, 1829, pp. 9-10. 

2 Trans. Am. Med. Assoc, vol. viii., 1855, pp. 392-5. 



96 BENDING, PARTIAL FRACTURES, AND FISSURES. 

Jurine attributes this restoration to " muscular action, or more espe- 
cially to the reaction of the compressed bony plates ;" but while it is 
easy to understand how the reaction of the compressed fibres may ac- 
complish the gradual restoration, I am unable to understand in what 
manner muscular action contributes to this result, since most of the 
muscles attached to the long bones operate so much more energetically 
in the direction of their axes than in the direction of their diameters. 
Indeed, we have often seen these bones bent after complete fractures, 
and before the union was consummated, by muscular action alone. 

I repeat, then, that the gradual restoration of these bones is due to the 
same circumstance which produces at other times an immediate restora- 
tion, namely, the elasticity of the unbroken fibres, but which elasticity, 
in this latter instance, is, for a time, effectually resisted by the bracing 
of the broken fibres. At length, however, in consequence of the gradual 
absorption of the broken ends, the resistance is removed, and the bone 
becomes straight. If this absorption refuses to take place, and the fibres 
continue pressed forcibly against each other, as in the case described by 
Campaignac, then the bone remains permanently bent. 

Having straightened the bone as far as is practicable, it only remains 
to secure the fragments in place by suitable bandages or splints. If the 
restoration is incomplete, these means may assist the efforts of nature in 
accomplishing a gradual restoration. 

It is scarcely necessary to say that extension and counter-extension 
avail nothing in partial fractures. 

§ 3. Fissures. 

These constitute the second principal form of incomplete fractures, or 
those in which the fracture is accompanied with no appreciable bending, 
which occur almost exclusively in inflexible bones, such as the compact 
bones of adults, and more often in the direction of their axes than of 
their diameters. They are complete so far as they extend, but they do 
not completely sever the bone so as to form two distinct fragments. 
They have been most frequently observed in the flat bones, such as the 
bones of the skull, and in the upper bones of the face ; occasionally in 
the long bones, both in their diaphyses and epiphyses, and rarely in the 
short bones. 

M. Gariel has reported, in the Bulletins de la Societe Anat., for 
1835, a case of fissure of the inferior maxilla, occurring in a lad sixteen 
or eighteen years old. Palletta found a fissure extending partly through 
the third dorsal vertebra, in a man who had fallen upon his back eleven 
days before ; and M. Lisfranc has mentioned a remarkable case of fissure 
and partial fracture, with bending of five ribs in the same person. 1 
Malgaigne believes that he has seen one example of this variety of in- 
complete fracture of the scapula, occurring through a portion of the in- 
fraspinous region. I have myself elsewhere recorded another, as having 
been found in the skeleton of Nimham, an Oneida Indian, who was a 



1 Des Fract. Incomplet. et des Fissures, par J. A. J. Campaignac, 1829, p. 20. 



FISSURES. 97 

great fighter, and who died when about forty-five years old in conse- 
quence of severe injuries received in a street brawl ; but his death did 
not occur until four or five months after the receipt of the injuries. 

In addition to this fracture of the right scapula, five of his ribs were 
broken, and both legs, all of which, except the scapula, had united com- 
pletely b}^ intermediate and ensheathing callus. 

The scapula was broken nearly transversely, the fracture commencing 
upon the posterior margin at a point about three-quarters of an inch 
below the spine, and extending across the body of the bone one inch 
and three-quarters, in a direction inclining a little upwards, being ir- 
regularly denticulate and without comminution. The fragments were 
in exact apposition, and, throughout most of their extent, in immediate 
contact. They were, however, not consolidated at any point, but upon 
either side of the fissure there was a ridge of ensheathing callus, of from 
one to three or four lines in breadth, and of half a line or less in thick- 
ness along the broken margin, from which point it subsided gradually 
to the level of the sound bone. The same was observed upon the inner 
as well as upon the outer surface of the scapula. The callus had as- 
sumed the character of complete bone, but it was more light and spongy 
than the natural tissue, and the outer surface had not yet become lamel- 
lated. Its blood-canals and bone-cells opened everywhere upon the sur- 
face. 

Directly over the fracture, and between its opposing edges, no callus 
existed, but as the bone had lain some time in the earth before it was 
exhumed, it is probable that a less completely organized intermediate 
callus had occupied this space, and that, owing to the less proportion of 
earthy matter which it contained, it had become decomposed and had 
been removed. 

M. Yoillemier found the head of the humerus penetrated by two or 
three fissures ; x and M. Campaignac has reported the case of a lad ten 
or twelve years old, who was compelled to submit to amputation of his 
arm at the shoulder-joint, in consequence of a severe injury, in which 
the humerus was found fissured from the insertion of the deltoid to near 
the condyles, extending through the entire thickness of the bone, and 
the edges of the fissure so much separated toward its lower extremity as 
to admit the blade of a knife. 2 Chaussier has related a case in which a 
criminal, who died soon after having submitted to the torture, was found 
to have a nearly longitudinal fissure of the radius in its upper fourth, 
and which penetrated half-way through the thickness of the bone. 3 Gul- 
liver saw a fissure in the pelvis of an infant. 4 Malgaigne has seen two 
specimens of this fracture in the iliac bones, both of which belonged, as 
he thinks, to adults ; in one, the fissure was limited to the internal 
table ; 5 and in the case of the lad reported by Gariel, as having a fissure 
of the inferior maxilla, there was also found a fissure of the left ilium, 
but which was limited to the outer table. 6 

1 Malgaigne, op eit., p. 35. 

2 Campaignac, Des Fract. Incomplete, etc., p. 24. 

Med. Legale, p. 447 et seq. « Gazette Med., 1835, p. 472. 

5 Op. cit , p. 34. 6 Bulletins de la Soc. Anat., 1835, p. 24. 



98 BENDING, PARTIAL FRACTURES, AND FISSURES. 

M. J. Cloquet lias mentioned a case of fissure of the shaft of the femur 
passing through the condyles and extending upwards to near the middle 
of the bone. The fissure was produced by a bullet, which had com- 
pletely traversed the bone from behind forwards, a little above the con- 
dyles. 1 - M. Malgaigne has also represented, in one of his plates, a fis- 
sure of the femur extending along the front of the bone, somewhat irreg- 
ularly, from a point a little below the trochanter minor to near the 
condyles. 2 The bone was presented to the museum of Val-de-Grace, by 
M. Fleury ; but it is to be regretted that we have no farther account of 
this remarkable specimen. Certainly in the complete absence of any 
farther history of the case, one might be justified in expressing a doubt 
whether it was not a fissure occasioned by the contraction consequent 
upon exposure and drying after death. 

The following account of a fissure of the neck of the femur, of the 
same character with those which now occupy our attention, is copied 
from the proceedings of the " Boston Society for Medical Improvement," 
at its regular meeting in September, 1856 : — 

" Partial Fracture of the Neck of the Femur in a man est. 44 years. 
Specimen shown by Dr. Jackson. The fracture, which appears as a 
mere crack in the bone, commences anteriorly just above, but very near 
to, the insertion of the capsular ligament, runs along the insertion for 
about an inch, and then extends directly upward to the margin of the 
head of the bone. From this last point it crosses the upper surface of 
the neck almost in a straight line, and at a little distance from the mar- 
gin of the head, but afterwards approaches very closely to this margin 
posteriorly ; it then turns downward and obliquely forward, and stops 
at a point about half way between the small trochanter and the head of 
the femur, and two-thirds of an inch or more anteriorly to the line of 
this trochanter. The fracture then involves about three-fourths of the 
neck of the bone ; the inner-anterior portion only being spared. There 
is considerable motion between the neck and the shaft, and the fracture 
could undoubtedly be completed without the application of any extraor- 
dinary force. Dr. J. referred to other cases of partial fracture ; but a 
fracture of this sort, as occurring in this situation, and in a fully adult 
subject, he believed had never before been described. There was, also, 
in this case, a transverse fracture of the same femur midway, with a 
split extending upward nearly to the neck of the bone ; and still further, 
a fracture of the spine. The patient, a laboring man, fell through two 
stories of a building and down upon a hard floor. On the same day he 
entered the Massachusetts General Hospital, and on the eighteenth day 
from the time of the accident he died. The femur is perfectly healthy 
in structure, and no changes are observable in the bone about the frac- 
ture." 3 

Whatever doubts may have been thrown upon the possibility of this 

1 These du Concours de Pathol. Externe, 1831, pi. xii. fig. 7. Also, Des Frac, 
etc., par Campaignac, 1829, p. 19. 

2 Opcit., p. 37, pi. 1, fig. 1. 

3 Bost. Med. and Surg. Journ., vol. lv. p. 351. See also Amer. Journ. Med. Sci. 
for 1857, p. 306, with engraving ; and Bigelow on Hip Joint, p. 137. 



FISSURES. 99 

accident, as applied to the neck of the femur, by the ingenious argu- 
ments of Robert Smith, of Dublin, 1 the question is now at least deter- 
mined by an incontestable fact. Dr. Smith had rendered it quite prob- 
able that both Colles and Adams were mistaken, and that the cases 
described by them were examples of impacted fracture, and not of par- 
tial fracture ; but in arguing the improbability of its occurrence, from 
the infrequency of fractures of the neck of the femur in early life, he 
overlooked the fact that there were two forms of incomplete fractures, 
and that it was only the " green stick" fracture which belonged mostly 
to childhood, " fissures" being found most often in the bones of adults. 
Indeed, I think the example recorded by Tournel in the Archives de 
Medecine had already, so early as the year 1837, established the possi- 
bility of a "fissure" in the neck of the femur ; although by Malgaigne 
this case has been mentioned as an example of that other variety of par- 
tial fractures which is almost peculiar to childhood, and in which the 
bones yield quite as much by bending as by breaking. But the man 
was eighty-five years old, and, having died three months and a half after 
the accident, a long crevice was found, extending nearly through the 
neck of the femur, partly within and partly without the capsule. 

I have seen, in Dr. Mutter's valuable collection of bones at Philadel- 
phia, a specimen of fissure of the trochanter major, which, it is believed, 
occasioned the death of the patient by hemorrhage. 

Gulliver says there is an example of a fissure in a patella belonging 
to the museum of the Edingburgh College of Surgeons, the fissure 
traversing its articular face only. 2 

The first example of a fissure of the tibia is recorded by Corn. Stalpart 
Vander-Wiel, in 1867 ; and indeed this is, according to Campaignac, 
the first exact observation of this species of fracture which our science 
possesses, although its existence had been recognized by the most an- 
cient authors. A servant had been kicked by a horse, and after a 
time, pain continuing in the limb, his surgeon, Dufoix, suspected a fissure 
of the tibia, and having cut down to the bone, a cure was soon effected. 3 

In the Dupuytren Museum, at Paris, there are two tibiae with linear 
fractures, one without history, and the other presented by MM. Mar- 
jolin and Rullier, " and which had been broken by a ball." 4 In the 
example related by Campaignac, a woman, having leaped from a second- 
story window, died immediately, and upon examination she was found to 
have three fissures in the upper portion of the left tibia, one only of 
which entered the articulation. 5 

Many examples of fissure from " perforating" gunshot wounds of the 
bone have been observed during the late war in this country, but as these 
examples belong peculiarly to military surgery, they will be discussed 
more at length in the chapter on gunshot fractures. 

Duverney saw a priest who had fallen and bruised the middle of his 
left leg, the swelling and pain consequent upon which were subdued 

1 Treatise on Fractures in the vicinity of Joints, etc., by Robert "Win. Smith, Dub- 
lin, 1854, p. 44 et seq. 

2 Malgaigne, op. cit., p. 35. 3 Campaignac, op. cit., p. 17. 
4 Malgaigne, op. cit., p. 36. 5 Campaignac, op. cit., p. 21. 



100 BENDING, PARTIAL FRACTURES, AND FISSURES. 

after a few days. The patient believed himself cured, and acted ac- 
cordingly. Suddenly, in the night, he was seized with an acute pain 
in the limb ; and on cutting down to the bone, a bloody serum escaped 
from between it and the periosteum, and the bone was discovered to be 
fissured longitudinally. Subsequently the tibia was trephined, but the 
fissure did not reach the marrow. He recovered completely in less than 
two months. 

The same writer mentions another case, in which a soldier received 
the kick of a horse in the middle of his left leg, which was followed 
immediately by great pain, and subsequently by much inflammation, and 
even gangrene of the skin. The wound, however, cicatrized kindly, 
but after three months he was seized suddenly with a severe pain in the 
limb, and after the trial of many remedies, resort was finally had to the 
knife, when the tibia was seen to be discolored and cracked longitudi- 
nally. On the following day the bone was opened over the course of 
the fissure with a chisel and mallet, and the patient was at once relieved 
by the escape of a yellowish and very offensive matter. At the next 
dressing the bone was opened more freely by several applications of the 
trephine, and an abscess was exposed in the centre of the bone. The 
patient finally recovered after about four months. 1 M. Campaignac 
saw, also, at the hospital La Charite, the tibia of a woman, set. 38 years, 
upon which were found four fissures, the report of which case is accom- 
panied with a wood-cut illustration. 2 

Fissures may occur probably at all periods of life, but they are more 
frequently found in the bones of adults. Campaignac, however, men- 
tions a fissure of the humerus in a child ten or twelve years old, and 
Gulliver has seen a fissure in the pelvis of an infant. 

Etiology. — They may be occasioned by most of those causes which 
produce fractures in general, such as direct or indirect shocks ; but 
they are occasioned much more often by direct blows, especially when 
inflicted upon bones imperfectly covered by soft parts, such as the tibia. 
Bullets, having violently struck or penetrated the bone, have frequently 
occasioned fissures. 

Their course may be parallel with the axis of the bone, oblique, or 
transverse ; they are often multiple ; some merely enter the outer lam- 
inae, others open into the cellular tissue, and others still divide both 
surfaces of the bone through and through ; and, according as they pene- 
trate more or less deeply the bone, their lips will be found to be more 
or less separated. They frequently extend into the joint surfaces. 

Diagnosis. — The signs which indicate the existence of a fissure must, 
in a large majority of cases, be insufficient to determine fully the diag- 
nosis during the life of the patient. It is not probable that such fissures 
could ever be clearly made out by the touch alone, where the skin is 
not broken, since the pain, swelling, suppuration, etc., are only charac- 
teristic of inflammation of the bone or of its coverings, and might be 
equally present whether a fracture existed or not. In those rare cases 
only in which the flesh is torn off, and the surface of the bone is brought 



1 Malgaigne, op. cit., p. 39 et seq. 2 Campaignac, op. cit., pp. 21-22. 



OSSA NASI. 101 

directly under the observation of the eye, will the diagnosis become 
certain. 

Treatment. — Fortunately, an error in judgment in this matter will 
not materially, if at all, prejudice the interests of the patient ; since, 
whatever may be the fact in other respects, if the bone, or its perios- 
teum, or its medullary tissue, is inflammed, and rest, with antiphlogis- 
tics, does not accomplish its speedy resolution, incisions and perforations 
become inevitable, if we would give either safety or relief to the suf- 
ferer. Accordingly, in the inflammation and suppuration consequent 
upon these fractures, we have seen that it has been occasionally found 
necessary to lay open the soft tissues freely, and even to trephine the 
bone at one or more points. 

Fisssures in Cartilage. — I have once met with a fissure in the thyroid 
cartilage, which constitutes, so far as I know, the only example upon 
record of a fissure in cartilage. 1 



CHAPTEE IX. 

FRACTURES OF THE XOSE. 

§ 1. Ossa Nasi. 

Of twenty-five cases of fracture of the ossa nasi recorded by me in 
my first edition, only fourteen were seen 'by a surgeon in time to afford 
relief. It seemed to me necessary, therefore, that the student should be 
instructed how frequently the nature of this accident is overlooked by 
the friends, and even by the surgeon himself, to the end that he might 
be thus admonished of the necessity of always instituting, in such cases, 
careful and thorough examinations. In some of the cases recorded in 
my notes, where surgeons were called in time, and a deformity remains, 
it is not improbable that the accident was not recognized. The rapidity 
with which swelling ensues after severe blows upon the nose, concealing 
at once the bones, and lifting the skin even above its natural level, ex- 
plains these mistakes. The nose, also, is remakably sensitive, and the 
patient is often exceedingly reluctant to submit to a thorough examina- 
tion. It ought, however, not to be forgotten that the omission on the 
part of the surgeon to do his duty will not always be excused, even 
though the patient himself has protested against his interference, espe- 
cially where an organ so prominent, and so important to the harmony of 
the face, is the subject of his neglect or mal-adjustment ; since the most 
trivial deviation from its original form or position, even to the extent of 
one or two lines, becomes a serious deformity. 

"When the ossa nasi are struck with considerable force, from before 
and from above, a transverse fracture occurs usually within from three 
to six lines of their lower and free margins, and the fragments are sim- 

1 Buffalo Med. Journ., vol. xiii., article entitled Fracture of the Thyroid Cartilage. 



102 FRACTURES OF THE NOSE. 

ply displaced backwards ; or if the blow is received partially upon one 
side, they are displaced more or less laterally. This is what will happen 
in a great majority of cases, as I have proven by examinations of the 
noses of those persons who have been the subjects of this accident, and 
by repeated experiments upon the recent subject. 

These fragments are generally loose, and easily pressed back into 
place by the use of a proper instrument. A silver female catheter, 
which we have seen recommended by surgeons, may answer well enough 
in a few instances, but it will more often fail. The diameter of the 
meatus at the point where the instrument must touch in order to make 
effective pressure upon the ossa nasi, is on the average not more than 
two lines ; and when the membrane which lines it is injured, it becomes 
quickly swollen, and reduces the breadth of the channel to a line or less. 
Under these circumstances, any instrument of the size of a female catheter 
could only be made to reach and press against the nasal process of the 
superior maxilla, which is too firm and unyielding to allow it to pass 
without the employment of unwarrantable force. In this way it happens 
that the operator is occasionally surprised to find how much resistance 
is opposed to his efforts to lift the bones, and, after repeated unsuccess- 
ful attempts, the case is not unfrequently given over. If, however, he 
had used a smaller instrument, he would have found almost no resistance 
whatever. A straight steel director, or sound, or sometimes even a 
much smaller instrument, if possessing sufficient firmness, is more suit- 
able than the catheter. For the same reason, also, one ought never to 
wrap the end of the instrument with a piece of cotton cloth, as some 
have, I suspect, without much consideration, recommended. 

What I have said of the facility with which these bones may be re- 
placed, when a proper instrument is employed, is true only when the 
treatment is adopted immediately, or at most within a few days after the 
accident. 

Boyer, Malgaigne, and others have noticed the fact that these frac- 
tures are repaired with great rapidity. Hippocrates thought the union 
was generally complete in six days ; and in a case which has come under 
my own observation, the fragments were quite firmly united on the 
seventh day. 

Nor has Malgaigne, whose observations are always very accurate, 
overlooked the fact, also, that their repair is effected without the inter- 
position of provisional callus, but as it were, " par premiere intention." 
My own observation confirms this statement. Among all the specimens 
which I have seen in the various college and private collections illus- 
trating fractures of the ossa nasi, and amounting in all to over forty, in 
no instance has there been detected, after a careful examination, the 
slightest trace of provisional callus. 

I am not certain that it will always be found so easy to retain these 
loose fragments in place, as it is to replace them. The very swelling 
which takes place so promptly under the skin tends to depress the frag- 
ments, unsupported as they are by any counter-force ; a tendency which, 
possibly, is in some instances increased by attempts on the part of the 
patient to clear his nostrils by snuffing and hawking. I have, in one 
instance, noticed very plainly a motion in the fragments when such 



OSSA NASI. 108 

efforts were made. How we are to remedy this, T am not prepared to 
say. None of the plans which I have seen suggested possess, in my 
estimation, very much practical value. Few patients will consent to the 
introduction of pledgets of lint, or of stuffed bags, or, indeed, of any- 
thing else, sufficiently far up into the nostrils to answer any useful pur- 
pose. The membrane is too sensitive and too intolerant of irritants to 
enable us to have recourse generally to such methods. Then, too, it 
would require, on the part of the surgeon, more than ordinary tact to 
accomplish so nice and delicate an adjustment of the supports from be- 
low as these cases demand, where the slightest excess of pressure, or 
the least fault in the position of the compress, must defeat the purpose 
of the operator. 

Yet, if one were disposed to make the attempt in certain cases where 
the comminution was very great, or where, for any other reason, the 
fragments would not remain in place, I think there could be no better 
plan than to push up in succession a number of small pledgets of patent 
lint, smeared with simple cerate, to each one of which there has been 
attached a separate string, so arranged that their relative position may 
be recognized, and that they may at a suitable time be removed in the 
order of their introduction. 

The employment of canulas, as recommended by Boyer, B. Bell, and 
others, allows of the nostrils being stuffed without interfering materially 
with the breathing; a provision, however, which is quite unnecessary 
with a majority of persons, so long as there exists no impediment to the 
free admission of air through the fauces. 

With nicely adjusted compresses made of soft cotton or lint, and se- 
cured upon the outside of the nose with delicate strips of adhesive plaster 
or rollers, we shall be better able to prevent the fragments from becoming 
displaced outwards than by moulds of wax, of lead, or of gutta percha, 
under which it is impossible to see from hour to hour what is transpiring. 

The complicated apparatus devised by Dubois and recommended by 
Malgaigne, to lift the bones and retain them in place, seems to me indeed 
very ingenious, but destitute of a single practical advantage. 

Supporting the fragments with a nickel-plated or gilded needle, which 
is made to transfix the nose at a point just below the fragments, has been 
suggested by Dr. Lewis D. Mason, of Brooklyn. 1 The method may prove 
useful in certain cases, but as yet it needs for its full endorsement the test 
of experience. 

A more considerable force than that which I have first supposed will 
break, generally, the ossa nasi transversely and a little above their mid- 
dle, while, at the same time, the nasal processes of the superior maxillary 
bones may suffer slightly. 

With neither of these accidents is the cribriform plate of the ethmoid 
likely to be broken or disturbed. Indeed, in numerous experiments made 
upon the recent subject, and in which the force of the blow was directed 
backwards and upwards, breaking and comminuting the nasal bones above 
and below their middle, with also the nasal processes of the superior 
maxillary bones, and the septum nasi, the cribriform plate of the ethmoid 

1 Mason, Annals of the Anatomical and Surgical Society of Brooklyn, March, 1880. 



lOi FRACTURES OF THE NOSE. 

was, without an exception, uninjured. The exceeding tenuity and flexi- 
bility of the septum nasi at certain points prevents effectually the con- 
cussion from being communicated through it to the base of the brain. 
If, therefore, after these accidents, cerebral symptoms are occasionally 
present, as I have myself twice seen, 1 they must be due rather to the 
concussive effects of the blow upon the very summit of the nasal bones, 
where they rest immediately upon the nasal spine of the os frontis, or to 
some direct impression upon the skull itself. 

The amount of force requisite to break in the nasal bones, at their 
upper third, is very great; no less, indeed, than is requisite to fracture 
the os frontis. If they do finally yield at this point, then no doubt the 
base of the skull must yield also. Nor do I think patients could often 
be expected to recover from an accident so severe. To this class of frac- 
tures belongs the specimen contained in my museum, in which not only 
both of the nasal bones are sent in — the nasal spine being broken at its 
base — but also the os frontis is depressed; the nasal processes of the 
upper maxillary bones are broken and greatly displaced, and the anterior 
half of the cribriform plate of the ethmoid is forced up into the base of 
the brain. If it is meant that in these cases the patient is in danger 
from injury done to the base of the skull through the fracture and depres- 
sion of the ossa nasi, we can appreciate the value of the opinion; but 
we do not understand how this danger can exist when the nasal spine of 
the os frontis is not broken, and the upper ends of the nasal bones are 
not displaced backwards. But, admitting that it were possible in this 
way to force up the base of the skull, it does not seem to me that we 
ought to attach any value to the advice occasionally given, to attempt to 
restore the broken ethmoid by seizing upon the septum and pulling down- 
wards. A force sufficient to break the base of the skull never fails to 
comminute and detach almost completely the septum nasi. We are to 
proceed in such a case as we would in a case of broken skull. We must 
lay open the skin freely, and with appropriate instruments seek to elevate 
and remove, if necessary, the fragments. Indeed, after such accidents, 
we shall generally see plainly enough that death is inevitable, and that 
our services will be of no value. 

Occasionally, I have observed, the bones are neither broken at their 
lower ends nor through their central diameters, but only at their lateral, 
serrated, or imbricated margins. This is rather a displacement, or dislo« 
cation, than a fracture. It is more likely to happen, I think, in childhood 
than in middle or old age, as in the following example: — 

Thomas Kelley, aged four years, was kicked by a horse. Two hours 
afterwards, when he was first seen by a surgeon, the nose and face were 
much swollen, and the fracture was overlooked. 

One year after the accident, I found both nasal bones depressed through 
nearly their whole length, and especially in the lower halves. The right 
nasal process was also much depressed, and the right nostril obstructed. 
The lachrymal canals upon this side were closed. 

Sometimes the lower ends of the nasal bones are bent backwards, or 
laterally, constituting a partial fracture. 

1 Report on Deformities after Fractures, Cases 16 and 18. 



OSSA NASI. 105 

A lad, aged ten years, was hit by one of his mates accidentally with 
his elbow, upon the left side of his nose. I was immediately called, and 
found the lower end of the left os nasi displaced laterally and backwards, 
so that it rested under the lower end of the right os nasi. There did not 
appear to be any fracture beyond that which was inevitable by the mere 
separation of its serrated margins from the bone adjoining. The angle 
formed by the bone at the point where the bending had occurred was 
smooth and rounded, and not abrupt as in a complete fracture. 

With a steel instrument, introduced into the left nostril, I attempted 
to lift the bone to its place. The membrane was very sensitive, and the 
patient very restless under my repeated efforts. I pressed upwards with 
considerable force, and succeeded at length in bringing the bone nearly 
into position. 

If there is more complete displacement, the upper ends are not usually 
forced backwards, but rather a very little forwards, from their articula- 
tions with the os frontis, and the bones then swing, as it were, upon the 
lower ends of the nasal spine, as upon a pivot. In this condition they 
are very firmly locked, and it requires considerable force, applied under 
their lower extremities, to restore them to place. 

Such seemed to be the position of the bones in the case of the lad 
Kelley, already mentioned, and also in a German, whose nose was flat- 
tened by a severe blow when he was eleven years old, whom I saw, 
thirteen years after the accident, in the Buffalo Hospital. In this last 
example the bones were very much displaced backwards. 

In children, also, the nasal bones may be spread and flattened, the 
lateral margins not being depressed or displaced, but only the mesial line 
or arch forced back, so as to press aside the processes of the superior 
maxilla ; which deformity may become permanent. 

A block of wood fell upon a child three weeks old, as she was lying 
in the cradle. The nature of the injury was not understood by the 
parents, and no surgeon was called. The ossa nasi are now, twelve 
years after the accident, much wider than is natural, and depressed ; the 
nasal processes of the superior maxilla appearing to have been spread 
asunder. 

Jacob Kibbs, a German, aged seven years, fell from a height of forty 
feet, striking on his face. His parents did not suspect the injury, and 
no surgeon was called. Twenty -four years after this, I found the nose 
almost flat. The nasal bones appeared unusually wide, and were sunken 
between the processes of the upper maxillary bones, which latter might 
be recognized by two parallel ridges on each side, slightly rising above 
the level of the ossa nasi. 

Benjamin Bell and others have spoken of tedious ulcers, polypi, necrosis, 
fistula lachrymalis, abscesses, impeded respiration, and impairment of 
the sense of smell and of speech, as circumstances apt to result from 
these injuries, and it is certain that such consequences have occasionally 
followed ; but they must generally be regarded as accidents due to the 
state of the general system, and as having no connection with the frac- 
ture, except as this injury served to awaken certain vicious tendencies. 

A gentleman twenty -five years old was struck accidentally upon the 
right side of his nose by a board, and the ossa nasi were displaced to 
8 



106 FRACTURES OF THE NOSE. 

the left. A surgeon made an attempt to reduce them, but did not suc- 
ceed, and they have remained displaced ever since. The nose for a time 
was much swollen. A few months after the accident, a purulent discharge 
commenced from' the right nostril, and at length an abscess formed in the 
right cheek. Two years later, when he came first under my notice, the 
nose still continued to discharge pus, and occasionally it bled freely. 
There was also a perforation of the septum, of the size of a three-cent 
piece, which had not ceased to enlarge. 

No hereditary maladies exist in the family, except that, on his father's 
side, it has been generally observed that wounds do not heal kindly. 
The same is the fact with him. When a child, he was also very subject 
to epistaxis ; at sixteen, a pulmonary difficulty began, and he had more 
or less cough, with haemoptysis, for two years. Since then his health 
has been good. He is a lawyer by profession, but of late he has lived 
in the country, upon a farm, and has accustomed himself to much out- 
door exercise. 

As to the prognosis in these fractures, I can only say that either owing 
to the ignorance and carelessness of the patients themselves, who neg- 
lect to call a surgeon in time, or to the difficulty of diagnosis, or to the 
greater difficulty in maintaining an adjustment of the fragments, it has 
hitherto happened that, after a fracture of the ossa nasi, more or less 
deformity has usually remained. I have seen but few which could be 
said to be perfectly restored. 

§ 2. Fractures and Displacements of the Septum Narium. 

Fractures or displacements of the septum narium must occur to some 
extent in all fractures of the ossa nasi accompanied with depression ; 
but they are also occasionally met with as the results of a blow upon 
the nose which has been insufficient to break the bones, and in which 
only the cartilaginous portion of the nose has been bent inwards upon 
the septum. 

Of these simple, uncomplicated accidents, I have seen eight ; in four 
of which no surgeon was employed, or surgical treatment of any kind 
adopted, and it is quite probable that only in a small proportion of all 
the cases was the nature of the accident recognized. Such, at least, has 
been generally the statement of the patients themselves. The same 
causes will explain this which have been invoked to explain similar over- 
sights in cases of broken ossa nasi. To which we may acid, as an addi- 
tional reason why it may be overlooked, the frequency of lateral distor- 
tions or deviations in the natural development of this septum. 

The cartilaginous portion of the septum is that which is most frequently 
displaced by violence, and then it is usually at the point of its articula- 
tion with the bony septum. Next, in point of frequency, the perpendicu- 
lar nasal plate is broken, and especially where it approaches the vomer. 
We omit in this enumeration, of course, those cases where the nasal bones 
themselves are broken down, in most or all of which, as we have already 
said, the perpendicular plate is more or less fractured and displaced. We 
cannot say how often the vomer is broken, since it is beyond our obser- 
vation, except in autopsies. It is probable, however, that the force of 



FRACTURES AND DISPLACEMENTS OF SEPTUM NARIUM. 107 

the concussion rarely reaches it, the cartilage or the perpendicular plate 
giving way first and easily. 

Where the deviation is only lateral, the results are less serious, yet 
sufficiently so, in a few instances, to demand our attention. Lateral 
obliquity of the lower portion of the nose follows generally, but not 
uniformly, a lateral displacement of the cartilage, and when it does ex- 
ist, it is not always proportioned to the amount of displacement existing 
in the septum, so that the septum is then made to project obliquely across 
the nasal passage, causing often a serious obstruction and permanent in- 
convenience. In one instance, also, I have known it to occasion a chro- 
nic catarrh. 

A lad, set. 15, was struck violently on the nose, which became imme- 
diately much swollen, but no surgeon was called. Eight years after I 
found the septum displaced laterally, and to the left side, producing also 
a slight lateral inclination of the end of the nose. He was unable to 
breathe freely through the left nostril, and from the same side a catar- 
rhal discharge had continued from the time of the accident. 

The following example, in which the accident has been followed by a 
morbid condition of the cutaneous glands, is of more difficult explana- 
tion : — 

A young man, get. 23, called upon me, supposing that he had a poly- 
pus nasi. I found that in consequence of a fall upon the ice, seven 
years before, the septum narium had been displaced to the right so as 
to almost completely close this nostril. In very cold weather, when the 
vessels of the membrane are contracted, the passage is more free. The 
left nostril is proportionally wide. 

During the last four or five years, the right side of his face has been 
subject to profuse perspiration. It is almost constant in summer, and 
only occasional in winter. The line of division between the perspiring 
and non-perspiring portions of the face passes perpendicularly from the 
top of the centre of the forehead, along the ridge of the nose, and down 
to the centre of the chin. The phenomenon is due, perhaps, to an in- 
creased vascularity in the right side of the face ; possibly to some pecu- 
liarity in the condition of the nervous trunks, occasioned by the nasal 
obstruction. 

A depression of the cartilage forming a portion of the ridge of the 
nose is necessarily accompanied with a corresponding degree of lateral 
displacement, with or without fracture, of its perpendicular portion, and 
produces, therefore, not only great deformity, sometimes a complete flat- 
tening of the end of the nose, but, also, in some instances, complete ob- 
struction of the nostrils. 

We conclude, from all that we have seen, that fractures and displace- 
ments of the septum narium are generally followed by permanent de- 
formity, and occasionally with still more serious results. We suggest, 
therefore, a more careful examination in recent injuries, with a view to 
the ascertainment of its lesions, and it would be well, certainly, if we 
could devise some reliable mode of treatment. 

It is doubtful whether a partition so thin and unsupported can ever be 
well adjusted and supported by artificial means. We possess, however, 
some advantages in the treatment of this accident which we do not in 



108 FRACTURES OF THE NOSE. 

the treatment of broken ossa nasi, viz., facility of observation and of 
approach, and if we can do little with plugs and supports in the one case, 
we may possibly do more in the other. Nothing seems more rational, 
then, than to ping carefully and equally each nostril with pledgets of 
lint, while we cover the outside of the nose completely with a nicely 
moulded gutta-percha splint or case, which ought to be made to press 
snugly upon the sides, and permitting these to remain for several weeks, 
or until the cure is completed. The papier mache of Dzondi, employed 
by him in cases of broken ossa nasi, would be equally applicable here ; 
but the gutta-percha, as being more plastic, and hardening more quickly, 
ought to be preferred. 

Attempts to remedy the deformities of the nose, at a later period, 
belong to the department of anaplastic surgery, and the modes of pro- 
cedure must be varied according to the circumstances of the case. 

The following example will serve as an illustration of what may some- 
times be accomplished in these cases : — 

A young man fell from a two-story window, striking upon his face. 
A surgeon was called, but he did not discover the nature of the injury 
to the nose. 

One year after the accident he called upon me for relief. The car- 
tilaginous portion of the septum was broken just at the ends of the nasal 
bones, and forced backwards about three lines, producing a striking de- 
pression at this point of the ridge of the nose, while at the same time 
the end of the nose was thrown up. The deformity was very unseemly, 
and annoying both to himself and to his friends, who at first could scarcely 
recognize him. 

I introduced a narrow, sharp-pointed bistoury through the skin of the 
nose on the right side, and resting its edge upon the ridge at the junc- 
tion of the cartilage with the ossa nasi, I cut the cartilaginous septum 
directly backwards about three lines, and then making a gradual curve 
with my knife, I cut downwards about eight lines toward the end of the 
nose. The intercepted portion of cartilage could now be easily lifted 
with a probe, and the line of the ridge of the nose completely restored. 
It was at once apparent, also, that lifting the cartilage would depress 
the tip of the nose and restore its symmetry. 

To retain the cartilage in place, I constructed a gutta-percha splint 
of the length and shape of the nose, but so formed along its middle as 
that it would not press upon the cartilage which I had lifted, resting 
well upon the ossa nasi, but not touching the ridge from the lower ends 
of these bones to the tip of the nose, at which latter point it again re- 
ceived support. I now passed a needle, armed with a stout ligature, 
through the upper end of the uplifted cartilage, transfixing, of course, 
the skin on both sides of the nose, and this I tied firmly over the splint. 
This accomplished the important object of pressing backwards and down- 
wards the tip of the nose, and thus tilting up the upper part of the ridge 
and septum, and of more effectually securing the cartilage in place by 
lifting it directly with the ligature. On the second day the ligature was 
removed, but the splint was continued two weeks, during most of which 
time a band was kept drawn across the lower end of the splint, and tied 
behind the neck. 



FRACTURES OF THE MALAR BONE. 109 

To prevent the cartilage from falling back when final cicatrization 
occurred, I pressed the sides of the splint firmly toward each other, just 
below the incision, so as to force as much as possible the walls of the 
nares into the fissure of the septum, made by lifting it up. The result 
is a complete and perfect restoration of the nose to its original form. 

Dr. James Boulton, of Richmond, Va., has devised a very ingenious 
mode of rectifying an old displacement of the septum nasi. He makes 
a stellate incision of the septum in such a manner as to form of it about 
eight triangles with their apices converging to a common centre. He 
then seizes each triangle separately with a pair of forceps, and breaks 
it at its base without detaching it. Having thus comminuted the septum, 
he is able to restore it to position and retain it until consolidation is 
effected. 1 



CHAPTER X. 

FRACTURES OF THE MALAR BONE. 

I have been unable to find any records of a simple fracture of the 
malar bone, that is to say, of a fracture unconnected with a fracture of 
other bones of the face. It is probable, however, that it sometimes 
occurs, but that, not being accompanied with much displacement, it is 
overlooked. I have myself seen a fracture of the upper margin, or of 
that portion which constitutes a part of the orbital border, in two or three 
instances, while I was unable to detect any other fracture among the 
bones of the face : but it is by no means certain that other fractures did 
not exist, perhaps in some of the bones which form the socket, or in the 
superior maxilla, as mere fissures, or as fractures with only slight dis- 
placement. The prominence of the malar bone, and especially the 
sharpness of its orbital margin, would enable the surgeon to detect easily 
the smallest displacement, or even a fissure, while a much more exten- 
sive displacement elsewhere would escape detection. 

The two upper maxillary bones form, as they are placed opposite to 
each other, an irregular arch, one end of which rests upon its fellow, at 
the intermaxillary suture, and the other end rests upon the nasal and 
frontal bones ; while over the centre of the arch is situated the malar 
bone. The force of a side blow upon the malar bone will expend itself, 
therefore, chiefly upon the base of the maxillary apophysis, as being in 
the line of the direction of the force. The force continuing to act, after 
the apophysis is broken, the portion of the superior maxilla above the 
floor of the nares will fall inwards toward the septum, while the portion 
below will tilt outward, and open the intermaxillary suture along the roof 
of the mouth. This suture will also open more widely in front than be- 
hind, owing to the greater depth of the suture in front. 

1 Bolton, Richmond Med. Journ., April, 1868, p. 241. 



110 FRACTURES OF THE MALAR BONE. 

These observations I have verified by several experiments made with 
a hammer upon a clean skull. 

One might suppose that it would be a very easy matter to restore 
these bones to place upon the naked skull, after such an accident. Cer- 
tainly it would be very desirable to do so, were this accident to occur to 
any patient, since the malar bone is slightly depressed, the nostril upon 
this side is nearly closed, and the line of the teeth is disturbed, and it is 
possible also that an opening might be established between the nose and 
mouth immediately back of the incisors. In fact, however, I found the 
restoration impossible. It could not be accomplished by an instrument 
within the nose pressing outwards, nor by pressing inwards upon the 
teeth and alveoli ; not, certainly, without very great and unwarrantable 
force. The difficulty consisted simply in the antagonism of the serrated 
margins of. the intermaxillary suture, which, projecting one or two lines 
on each side, could not be made to interlock again, but were firmly braced 
against each other. 

I shall not find it necessary to report in detail the results of the ex- 
periments, but shall content myself with stating that by the second blow, 
in the last experiment, the skull was also found broken at its base, 
through the lesser wings of Ingrassias ; the force of the blow having 
been conveyed, apparently, along the orbital plate of the superior max- 
illa and os planum. 

This is the only example from four experiments in which the fracture 
extended through the dental arcade, and it was the result of the first 
blow. The fracture of the base of the skull by the second blow indicates 
the possibility of producing a fatal lesion of the brain or of its bloodves- 
sels by a blow upon the malar bone. 

G-eneral Summary of results when the blow was inflicted directly 
upon the malar bone. — A fracture of the superior maxilla occurred 
in every instance ; and twice when the malar bone was not broken : in 
each of the two last cases the antrum alone was broken, and the depres- 
sion of the malar bone was scarcely noticeable. In the second of these 
cases, the fracture extended also through the dental arcade. 

In three cases the nasal apophysis was broken near the base, and in 
one case at two points. One of the three fractures of the nasal apophy- 
sis was accompanied with a diastasis of the superior maxilla through its 
intermaxillary suture. 

The malar bone has been broken twice by the first blow, and always 
when the blow has been repeated. The orbital margin and orbital 
plate have been fissured twice, the outer portion of the orbital plate 
being pushed a little into the socket. Once this plate has been pushed 
downwards. 

The zygoma has been broken three times, and always transversely a 
little beyond its centre, or where the bone is the most slender and most 
convex. 

The ethmoid has been broken three times, and always longitudinally 
through the orbital plate. 

The sphenoid has been broken once, at the base of the skull. 

In addition to these observations upon the naked skull, I have seen at 
least four examples, which illustrate the relative infrequency of fractures 



FRACTURES OF THE MALAR BONE. Ill 

of the malar bone, as compared with fractures of the superior maxilla 
and of the other bones of the face, even when the blow is received di- 
rectly upon the malar bone. 

Pat. Maloney, set. 55, fell about twenty feet and struck upon his 
face. Six weeks after the accident, while an inmate of the Buffalo 
Hospital of the Sisters of Charity, I found, the right malar bone de- 
pressed, but I could not trace any line of fracture in the malar bone. 
I think the antrum of the superior maxilla was broken, and the malar 
bone forced in upon it. 

Thomas Crotty, set. 20, was struck with a hoop, August 15, 1855. 
He was seen immediately by a surgeon in Canada, but the fracture was 
not recognized. Five days after, he called at my office. I found the 
outer portion of the right malar bone lifted slightly, and the lower and 
anterior angle depressed about three lines, as if this portion had been 
forced in upon the antrum. 

The third case will be found reported under fractures of the superior 
maxilla, and the fourth has been brought under my notice in the prac- 
tice of Dr. Wadsworth, of New York, the fracture having been occasioned 
by collision with the head of another man. 

Prognosis. — The malar bone may be depressed, as we have seen, to 
the extent of two or three lines, without being broken. This accident 
will be more properly considered under fractures of the upper maxilla. 
A fracture of the malar bone implies, therefore, generally, that great 
force has been applied, and that other fractures exist as complications. 
This may not be true, however, when only the orbital margin of the 
socket is broken. If the orbital plate is broken, and a portion of it is 
pushed into the socket, it may occasion a slight protrusion of the ball, 
as in two cases related by Dr. Neill as fractures of the upper maxilla, 
and as has been noticed in the experiments already referred to. This 
protrusion of the eyeball will probably continue, in some degree, as 
long as the bones remain displaced. It is quite probable, however, that 
in some cases, after severe injuries of the face, a moderate protrusion of 
the eyeball is due entirely to extravasation of blood in the socket ; a 
circumstance which would be likely to follow a fracture of the bones of 
the socket, and. to increase temporarily the protrusion of the eye. 

If the body of the bone is broken entirely through, and coma super- 
venes upon the accident, there is some reason to fear that the skull is 
fractured at its base, and the prognosis ought to be grave. 

Treatment. — If there is only a fissure of the orbital margin, it will 
not require attention; but if the fissure extends through the orbital plate, 
and at the same time the anterior and inferior margin of the bone is 
depressed, in consequence of which the orbital plate is tilted upwards 
and made to push forward the eyeball, the propriety of surgical inter- 
ference may be considered. If this protrusion is considerable, and 
evidently due to the displaced bone, an attempt should be made to lift 
the body of the malar bone, and thus to restore to position its orbital 
plate. The method of accomplishing this I shall describe particularly 
when speaking of fractures of the superior maxilla with depression of the 
malar bones. 



112 FRACTURES OF THE UPPER MAXILLARY BONES 



CHAPTEE XI. 

FRACTURES OF THE UPPER MAXILLARY BONES. 

These fractures assume so great a variety in respect to form, situa- 
tion, and complications, that it would be impossible to speak of them 
systematically, or to establish anything but very general rules as to 
treatment and prognosis. 

They may be broken, or loosened from each other or from the other 
bones with which they are articulated, with or without any farther frac- 
ture ; the nasal processes may be broken, and generally this accident 
is accompanied with a fracture of the nasal bones also ; the malar bones 
may be forced in, carrying with them a portion of the outer wall of the 
antrum ; the alveoli may be broken and more or less completely de- 
tached ; and either of these several fractures may be complicated with 
fractures of the other bones of the face, or of the base of the skull even. 

Treatment. — When the harmonies of the upper maxillary bones are 
only slightly disturbed, nothing but a retentive treatment is necessary. 

A man was thrown backward from a loaded cart, one wheel of the 
cart passing over his face. He was taken up unconscious, but when 
I saw him on the following morning, his consciousness had returned. 
The right malar bone was broken, and forced down upon the antrum 
about three lines. Both superior maxillae were loosened from their ar- 
ticulations, and could be moved laterally, the motion producing a slight 
grating sound. The same motion and grating occurred whenever he 
attempted to swallow. No effort was made to elevate the malar bones, 
nor did I find any means necessary to retain the maxillary bones in 
place, the amount of displacement being very inconsiderable, and never 
sufficient to be observed by the eye. Cool lotions were applied con- 
stantly to the face, and the patient was sustained by a liquid diet. On 
the ninth day all motion of the fragments had ceased, and on the twenty- 
seventh day the patient was completely recovered, with only the de- 
pression of the malar bone remaining. 

Sargent, of Boston, reports a similar case, in which a slight separa- 
tion of the maxillary bones united promptly and without any retentive 
apparatus. 1 

But in a case in which the superior maxillary bones had been more 
completely torn from their connections, complicated with other severe 
injuries, I found it necessary to support the fragments by closing the 
lower jaw upon the upper, and by suitable bandages. The patient died, 
however, on the twelfth day. 2 

1 Boston Med. and Surg. Journ., vol. lii. p. 378. 

2 Report on Deformities after Fracture. Trans. Amer. Med. Association, vol. viii. 
p. 375, Case IV. 



FKACTUKES OF THE UPPER MAXILLARY BONES. 113 

Graefe recommends, where the bones are thus extensively separated 
and displaced, an apparatus made of steel, and suitably covered, which 
is to be applied against the forehead and buckled under the occiput. 
From the two sides descend a couple of steel plates, which, having ar- 
rived at the free border of the upper lip, are reflected upon themselves, 
and are made to support upon their extremities long silver gutters, in- 
tended for the reception of not only the displaced teeth and alveoli, but 
also those teeth which are firm. 1 Vulcanized rubber might be substi- 
tuted for the silver in this apparatus. 

Wiseman, having been summoned to a child with his whole upper jaw 
forced in by the kick of a horse, " beating the ethmoides quite in from 
the os cribriforme," and forcing the palate bone against the back of the 
pharynx, found great difficulty in securing a permanent readjustment. 
At first he attempted to introduce his finger back of the bone, but 
failing in this, he bent an instrument into the form of a hook, and pass- 
ing it between the bone and the pharynx, he easily replaced the frag- 
ments. But, on removing the instrument, they were again displaced. 
Immediately he had constructed an instrument by which the bones could be 
not only easily reduced, but also retained in place, extension being made 
by the hands of the child, his mother, and others, alternately. In this 
way the reunion was finally effected, and " the face restored to a good 
shape, better than could have been hoped for." 2 

Harris, of New York, mentions a case in which a child, two years 
old, having fallen from a height of fifty feet upon the pavement, was 
found to have a diastasis of both the superior maxillary and palate 
bones ; the separation being sufficient to admit the little finger, and 
extending from between the alveoli which supported the central in- 
cisors, to the soft palate. It is not said whether any efforts were made 
to reduce the bones, but six weeks after the injury was received they 
were still open, and it was proposed to close the space by a plastic 
operation as soon as the condition of the patient would warrant such a 
procedure. 3 

I suspect that in this example, as in my experiments referred to under 
fracture of the malar bone, it was found impossible to adjust the bones 
and close the intermaxillary suture, and for the same reasons. 

If, in consequence of a blow received upon the ossa nasi, the nasal 
processes of the superior maxillae are broken down, they may be lifted 
and adjusted in the same manner as the ossa nasi. 

I have seen several examples of this accident, and I have in my 
cabinet a specimen, in which the nasal bones being driven in by the 
kick of a horse, the nasal process upon the left side is broken off just 
above the root of the cuspid tooth, and its upper end inclined inwards 
toward the nasal passage and backwards, until it is completely buried. 
In this situation it has become firmly united to the bony and soft tissues 
into which it was brought in contact. 

The following example will illustrate some of the complications and 

1 Traite des Frac. etc., par L. F. Malgaigne, p. 373. 

2 Chirurgical Treatises, by Richard Wiseman, 1734, p. 443. 

3 New York Journ. Med., vol. xiii., 2d ser., p. 214. 



114 FKACTUKES OF THE UPPER MAXILLARY BONES. 

difficulties connected with a depression of the malar bone, and conse- 
quent fracture of the antrum maxillare. 

M. P., of Colesville, aged about 34 years, was thrown from a height, 
striking upon his face, forcing the right malar bone down upon the 
antrum of the superior maxilla. Dr. L. Potter, of Varysburg, and 
myself were called. 

The deformity produced by the sinking of the malar bone was very 
striking, and both the patient and myself were very anxious to have it 
remedied, if possible. We found some of the teeth upon the side of 
the fracture loose, and we determined to extract them, and press up 
the bone with an instrument introduced through the empty sockets. 
The first attempt to extract a molar tooth, however, brought down 
several teeth, and the whole floor of the antrum. The detachment of 
this fragment was also now so complete that we believed it necessary to 
remove it entirely, a labor which was accomplished with infinite difficulty, 
and with no little hazard to the patient, as dissection had to be extended 
very far back into the throat, and in the end it was not effected without 
bringing out, attached to the fragment of maxillary bone, a considerable 
portion of the pyramidal process of the os palati. 

The time occupied in this operation was at least one hour, during 
which we were every moment in the most painful apprehensions lest we 
should reach and wound the internal carotid, which lay in such close 
juxtaposition to the knife that we could distinctly feel its pulsation. 
After its removal, the hemorrhage was for an hour or more quite profuse, 
and could only be restrained by sponge compresses pressed firmly back 
into the mouth and antrum. 

When the hemorrhage was sufficiently controlled, we proceeded to 
examine the antrum, the 'floor of which being removed entire, per- 
mitted the finger to enter freely. The restoration of the malar bone 
was now accomplished without much difficulty, and with only moderate 
force. 

Two years after the accident the face presented, externally, no traces 
of the original injury. The malar bone seemed to be as prominent as 
upon the opposite side, and there was no perceptible falling in where 
the teeth and alveoli were removed. During several months after the 
removal of the bone, the antrum continued to discharge pus, but at 
length a semi-cartilaginous structure closed in the cavity below, entirely 
reconstructing its floor, and the discharge ceased. Since then he has 
experienced no further inconvenience. 

I wish to propose two or three expedients for lifting the malar bone 
when it has been thrust down, which may in certain cases be substituted 
for the mode which has been heretofore generally adopted. 

In many instances no difficulty will be experienced in resorting to 
the usual method. The recent loss of one or more teeth opposite the 
floor of the broken antrum, or the complete displacement of a tooth 
by the accident itself, will give an opportunity for the perforation of 
the antrum through the open socket, and for the introduction of a 
suitable instrument for lifting the depressed bone. Unless, however, 
the opening is quite large, the instrument employed must be so small, 
such as a straight steel sound or a female catheter, as to expose the 



FRACTURES OF THE UPPER MAXILLARY BOXES. 115 

parts against which its end is made to press, to some risk of being 
broken and penetrated. It is even possible in this way to penetrate 
the socket of the eye, and thus inflict serious injury upon the eye itself. 
Yet with some care, such accidents may be avoided, and it is probable 
that in the cases supposed, where the sockets of the teeth opposite the 
base of the antrum are open, this method will continue to have the 
preference. 

But if the teeth remain firm in their places, or if they have been some 
time removed, and the sockets are filled up, and we wish to enter the 
antrum at its base, we must either drill through its anterior wall above 
the roots of the teeth, or we must proceed to extract a tooth. The first 
method gives an inconvenient opening, and one through which it will be 
necessary to use a curved instrument ; but yet it is a method far less 
objectionable than the extraction of a tooth which is firm, or which is 
even tolerably firm, in its socket, and which may require the forceps for 
its removal. The objections to this latter procedure were suggested by 
the tedious and painful operation already detailed. The first attempt to 
extract a tooth brought down the whole floor of the antrum, with all its 
corresponding teeth, and the pyramidal process of the palate bone. The 
tooth was already loose, and we thought it might easily be taken out, 
but it had not occurred to us that it was loosened by the comminuted 
condition of the walls of the antrum, and of the dental arcade. The ex- 
periments made upon the dead subject would seem to show that this frac- 
ture and comminution of the alveoli is not a very frequent result of a 
fracture of the antrum produced by a blow upon the malar bone ; yet it 
may happen, and whenever it does, the attempt to extract a tooth must 
always expose the patient to the same hazards. Certainly it is no tri- 
fling matter to pull away all of a man's upper teeth upon one side, and 
to open freely into a broad cavity which might never close again, and 
which, in this event, must always serve as a place of lodgment for par- 
ticles of food, and for foul secretions, to say nothing of the external de- 
formity which it is likely to produce, and of the severity and even danger 
of the operation. 

I wish, then, to suggest certain procedures, the value of which I have 
been able to determine by experiment upon the living subject in two 
or three cases, and which I have carefully and frequently tested upon 
the cadaver. 

First, we ought to attempt to lift the bone by putting the thumb under 
its zygomatic process and body within the mouth. If the bone is thrown 
directly downwards, or downwards and backwards, this method can 
scarcely fail ; and even when it is thrown downwards and forwards, so 
as to press into the antrum, it is likely to succeed. If, however, for any 
reason, the thumb cannot be brought to bear upon its under surface, we 
may make a small incision upon the cheek over the anterior margin of 
the masseter muscle, where its insertion into the malar bone terminates, 
and pushing a strong blunt hook under the bone, we may lift it with ease. 

Where the depression of the malar bone is in the direction of the an- 
terior and superior angle, these means may not be found available, and we 
may then employ a screw elevator, an instrument which I find already 
constructed in a ease of trephining instruments made for me by Mr. 



116 FRAOTUEES OF THE UPPEE MAXILLARY BONES. 

Liier, of Paris, and which I have often used, and constantly recommended 
to my pupils, in certain cases of fractures of the skull. The instrument 
ought to be made of the best steel, and with a broad, sharp-cutting thread. 
A slight incision being made through the skin, and down to the centre 
of the malar bone, the elevator is then screwed firmly into its structure, 
and now its elevation and adjustment may be accomplished wtth the 
greatest ease. 

Malgaigne remarks : " In all complicated fractures of the upper jaw, 
there is one principle which surgeons cannot too much study, namely, 
that all fragments, however slightly adherent they may be, ought to be 
most carefully preserved, and they will be found to unite with wonder- 
ful ease. This remark had already been made by Saviard, Larrey in- 
sists strongly upon it, and we have seen that M. Baudens, so great an 
advocate for the removal of loose fragments, has declared for these frag- 
ments a special exemption." 1 

Malgaigne has here especial reference to fractures of the dental ar- 
cade, and to fractures implicating the alveoli, and extending more or less 
into the body of the bone. 

It would be an error, however, to suppose that a reunion will in these 
cases uniformly take place. Exceptions have occurred in my own prac- 
tice, the fragments becoming loosened and completely detached after 
the lapse of several weeks. In the case related by Miller, the whole 
floor of the antrum having been broken off, in an unskilful attempt to 
extract the second right upper molar, it was found impossible to make 
it unite, and it was subsequently removed. 2 Such unfortunate results 
certainly may sometimes be reasonably anticipated. Yet they occur 
so seldom as to justify the opinions and practice advocated by Malgaigne. 

In some instances, where fragments are displaced, carrying with them 
several teeth, while others in the same row remain firm, it will be suf- 
ficient to close the mouth and apply a bandage as for fracture of the 
inferior maxilla ; in others, the teeth and their alveoli ought to be fast- 
ened with silk, or gold or silver thread ; gold, silver, gutta-percha, or 
vulcanite clasps may be applied to the teeth and jaw. 

In a case of fracture of the right superior maxilla, reported by Baker, 
of Norwich, N. Y., complicated with a fracture of the inferior maxilla, 
the alveoli were retained in place very perfectly by a mould of gutta- 
percha. 3 Neill, of Philadelphia, has also reported three cases of frac- 
ture of the bones of the face, involving the superior maxilla, in two of 
which the eyes were made to protrude more or less from their sockets. 4 
The loosened alveoli were, made fast by wire. The subsequent deformity 
was inconsiderable, yet in no instance was the restoration complete. 5 
The same method was adopted successfully by a surgeon in Virginia, in 
the case of a negro fifty years old, where most of the teeth of the left 
upper jaw were forced into the mouth, carrying with them their corre- 

1 Op. cit., vol. i. p. 376. Paris ed. 

2 News Letter, April, 1854. Also, Bost. Med. and Surg. Journ., vol. li. p. 264. 

3 New York Journ. of Med., vol. i., 3d ser., p. 362. 

4 See "Observations," under Fractures of the Malar Bone; in which the orbital 
plate of the malar bone was pushed into the sockets. 

5 Phil. Med. Exam., vol. x., new ser., pp. 455-8. 



FRACTURES OF THE ZYGOMATIC ARCH. 117 

sponding alveolar processes. The teeth remained firm in their sockets, 
but the separation of the bone was complete, the fragment being held in 
place only by the mucous membrane of the mouth. On the eighth day 
the surgeon found that the negro had removed the wire, and also the cork 
from between his teeth, and the maxillary bandage ; but the soft parts 
had already united, and the bones showed no tendency to displacement. 
His recovery was speedy, and it was accomplished without any further 
treatment. 1 

Our experience during the war of the rebellion in this country con- 
firms most of the observations heretofore made in relation to these frac- 
tures. Owing to the extreme vascularity of bones composing the upper 
jaw, the fragments have been found to unite, after the most severe gun- 
shot injuries, with surprising rapidity; the amount of necrosis and caries 
being usually inconsiderable, compared with the amount of comminution. 
The same anatomical circumstance, namely, the vascularity, has ren- 
dered these accidents peculiarly liable to troublesome hemorrhages, both 
primary and secondary. 

The Surgeon-General reports that of 4167 wounds of the face, tran- 
scribed from the reports from the beginning of the war to October, 1864, 
there were 1579 fractures of the facial bones, and of these 891 recovered, 
107 died — the terminations are still to be ascertained in 581 cases. He 
further remarks that secondary hemorrhage has been the principal source 
of fatality in these cases, and that frequent recourse has been had to 
ligation of the carotid, with the result of postponing for a time the fatal 
event. 2 



CHAPTEE XII. 

FRACTURES OF THE ZYGOMATIC ARCH. 

The zygoma, strictly speaking, is formed in a great measure by the 
body of the malar bone, and it is broken whenever the malar bone is 
completely separated through any portion of its body ; but I propose to 
confine my remarks to that portion only which is composed of the two 
processes, called respectively the zygomatic processes of the malar and 
temporal bone. 

Duverney relates a case in which a young child, having in his mouth 
the end of a lace-spindle, fell forwards and thrust the spindle through 
the mouth from within outwards, breaking the zygoma in the same direc- 
tion, and leaving the fragments salient outwards. 3 To which case of 
oiuVward displacement Packard, in a note to Malgaigne's work on frac- 
tures, etc., has added a second. 4 

I know of no other examples in which the fragments have been thrust 

1 Amer. Med. Gazette, vol. viii., new ser., p. 106. 

2 Circular No. 6, Washington, Nov. 1, 1865, p. 20. 

3 Bulletin de la Societe Anatomique, p. 138, 1810. 
* Op. cit., p. 289, vol. i 



118 FEACTURES OF THE ZYGOMATIC ARCH. 

outwards. A reference to my experiments upon the naked skull will, 
however, show that the zygoma may be broken and displaced in the same 
direction, by any force which shall fracture the superior maxilla, and 
depress the anterior margin of the malar bone. In my experiments this 
has happened three times, and always at the same point, viz., a little 
beyond the middle of the zygoma, near where the suture which joins the 
two processes terminates below. The fractures were always transverse, 
and not in the line of the suture. They were therefore fractures of that 
portion of the zygoma which belongs to the temporal bone. 

I suspect, also, that to this class of cases belongs the example related 
by Dupuytren, in which the patient having died on the fifth day, from 
the effects of the cerebral concussion, the autopsy disclosed " a fracture 
through the zygomatic arch ; and that part of the superior maxillary 
bone which constitutes the antrum was driven in." 1 

In another case mentioned by Dupuytren, produced by a direct blow, 
the fracture was compound and comminuted, and although the fragments 
were raised easily by an elevator, suppuration ensued beneath, and the 
matter was discharged within the mouth. 2 

Tavignot reports a case of fracture of this arch which was not dis- 
covered until after death, the fragments not being at all displaced. 3 

Dr. John Boardman, one of the surgeons to the Buffalo Hospital of 
the Sisters of Charity, informs me that he has met with a fracture of 
the zygoma in a man about thirty years of age, occasioned by a blow 
from a cricket-ball. Dr. Boardman saw him on the fourth day, and as- 
certained that immediately on the receipt of the injury he felt slightly 
stunned, and that he soon recovered from this, but was unable to open 
his mouth except by pulling it open with his hand ; neither could he 
close it except in the same manner. This immobility of the jaw con- 
tinued several days with only very slight improvement ; at the end of 
five weeks, however, when last seen, the mobility was nearly, but not 
quite restored. The depression, a little in front of the centre of the 
zygoma, was discovered by the patient himself immediately after the 
receipt of the injury, and he says he tried at once to ascertain whether 
he could not push the fragments back by moving the jaw. He was un- 
able to make any impression upon them by this manoeuvre. The depres- 
sion still remains, but it is not so distinct as it was when first seen. 

Barney Quirm presented himself at the Bellevue Dispensary, April 
17, 1871, stating that he had been hit by a stone, in blasting, three weeks 
before. There was a fracture, with depression, at or near the junction 
of the malar and temporal processes. The malar bone was elevated a 
little. From the time of the accident he had been unable to open his 
mouth more than half an inch. 

January 2, 1874, Anna McQuirk fell upon the side of her face. 
Seven days after the accident she consulted me. There was a fracture 
with depression at the junction of the malar bone with the zygoma. At 
first, and for a day or two, she could open and close her mouth easily, 

J Injuries and Diseases of Bones, by Baron Dupuytren. Syd. ed., London, 1847, 
p. 336. 

2 Op. cit., p. 335. 3 Bulletin de la Soc. Anat., 1810, p. 138. 



FRACTURES OF THE ZYGOMATIC ARCH. 119 

but when I saw her, the act of opening the mouth was painful and diffi- 
cult. Having introduced my fingers into the mouth, I attempted to press 
the fragment out, but was unable to make any impression upon it. 

It is plain that in this latter case, the inability to open the mouth was 
due to the inflammation resulting from the injury and not to the displace- 
ment of the bone, and that as the inflammation subsided the disability 
would disappear. 

John Crandall, an adult, fell upon a stone, February 21, 1875, striking 
upon the side of his face and head. He was stunned by the accident. 
On the following morning he could not open his mouth. Five weeks 
later I found the zygoma much depressed near its junction with the malar 
bone, the corresponding edge of the malar bone being a little lifted. 
There had been a gradual improvement in his ability to open his mouth, 
and he could now separate the teeth about half an inch. I advised him 
that he might expect a slow but complete restoration of the use of his 
jaw ; and if this did not occur within a few months, to call upon me again, 
and I would lift the fragments ; but as he has not returned, I infer that 
he recovered the use of his jaw. 

Symptoms. — An irregular projection or depression of the fragments 
is the only sign which can be relied upon to indicate the existence of this 
accident ; and this must often be concealed by the swelling which follows 
so rapidly wherever the integuments are severely bruised over a super- 
ficial bone. This displacement can scarcely occur in but two directions, 
either outwards or inwards ; since the attachments of the temporal 
aponeurosis above, and of the masseter muscle below, must effectually 
prevent its descent or ascent. 

Neither motion nor crepitus will often be present. In some cases the 
difficulty in opening or shutting the mouth, occasioned by the projection 
of the fragments toward or into the tendon of the temporal muscle, or 
by the inflammatory effusions, may assist in the diagnosis. 

Prognosis. — If the fracture has been produced indirectly by a de- 
pression of the malar bone, the prognosis must depend upon the amount 
of injury clone to the other bones of the face ; in itself, the fracture of 
the zygoma cannot be a matter of any moment. The same remark might 
apply also to any fracture of the zygoma in which the angles were salient 
outwards. If, on the contrary, the angle is salient inwards, the fracture 
having been produced by a blow inflicted directly upon the zygomatic 
arch from without, or by a blow upon the outer portion of the malar 
bone, it may occasion some embarrassment to the action of the temporal 
muscles. 

If the force which produces the fracture has acted more upon the tem- 
poral portion of the arch, near where the process arises from the temporal 
bone, it may be accompanied with a fracture of the skull, and with seri- 
ous cerebral lesions, as in one of the cases already alluded to as having 
been noticed by Dupuytren. 

The abscess which followed in the case of the compound, comminuted 
fracture, quoted from the same author, indicates the danger of this com- 
plication ; but it must be noticed that its evacuation resulted in a rapid 
cure, and that no deformity or difficulty in moving the jaw remained. 



120 FRACTURES OF THE ZYGOMATIC ARCH. 

Treatment. — A fracture, accompanied with an outward displacement, 
and occasioned by a depression of the malar bone, will be adjusted by 
a restoration of the malar bone in the manner already described, when 
speaking of fractures of the superior maxilla, etc. If the fragments are 
displaced outwards, in consequence of a direct blow from within, then 
they may be replaced by pressing upon the projecting angle. In this 
way Duverney easily reduced the bones in the case which I have cited. 

When the fragments, in consequence of a direct blow from without, 
have been driven inwards, and, as a consequence, serious embarrassment 
to the motions of the temporal muscle ensues, an attempt ought to be 
made at once to replace them ; if, however, no impediment to the action 
of the muscle exists, it is scarcely necessary to say that no surgical in- 
terference will be required. It is quite probable, indeed, that a slight 
amount of embarrassment may be the result of the direct injury to the 
muscle inflicted by the blow, without reference to the displacement of 
the bone, and that a few days will suffice to remedy this evil entirely ; 
and, moreover, experience teaches that in the case of a fracture in other 
bones, where the fragments actually penetrate the muscles and remain 
thus displaced, the points are gradually absorbed, and rounded, so that 
after a time they constitute no impediment to the action of the muscles. 
It is proper to infer that the same thing will occur here. The surgeon 
may be reminded, also, that it is not the muscle but its tendon which is 
liable to be penetrated ; and that this is usually protected, somewhat, by 
a plate of soft adipose tissue lying between the tendon and the arch. 

If to these considerations we add the difficulties which we shall be 
likely to encounter in the reduction, we shall expect to find but few cases 
in which a resort to surgical interference will be necessary. 

Duverney says that he restored a fracture of this arch, accompanied 
with depression, by pressing against the zygoma from within the mouth ; 
but an examination of the interior of the buccal cavity will convince us 
that this is impossible when the fracture is at any point near the middle 
of the zygoma ; and that it can be only when the fracture is at or near 
the junction of the zygoma with the body of the malar bone, that any 
effective pressure can be made from this direction. In such a case, we 
may, perhaps, lift the portion of the zygoma remaining attached to the 
malar bone, by the same means which have already been suggested for 
lifting the bone itself. 

If the bone is driven toward the tendon of the temporal muscle at or 
near its centre, and if its restoration becomes necessary, it can be ac- 
complished only by approaching the bone from without. 

Dupuytren found an external wound through which, by the aid of a 
levator, he easily restored the fragments to place. 

M. Ferrier, however, of the Hospital of Aries, in a case brought before 
him, made an incision through the integuments down to the bone, and 
then attempted to slide underneath the small extremity of a spatula ; 
but the aponeurosis would not yield, and he was obliged to cut it also. 
He was now able to lift the fragments easily. The wound healed rapidly, 
and the patient was dismissed without any deformity. 1 

1 Bulletin des Sciences M<§<i., torn. x. p. 160. 



FRACTURES OF THE LOWER JAW. 



121 



CHAPTER XIII 



FRACTURES OF THE LOWER JAW. 




Division. — Of 53 examples of fracture of this bone which have been 
recorded by me, not including gunshot fractures, 50 were broken through 
some portion of the body. 

Having made an analysis of 43 of the above examples, I find that 
15 were broken completely asunder at two or more points, constituting 
double and triple fractures ; and of the remainder, 5 were accompanied 
with detachment of portions of the 
alveoli, and one with detachment of 
a considerable fragment from the 
body. 

13 were compound ; not including 
in this enumeration several examples 
in which the partial or complete dis- 
lodgment of a tooth might entitle 
them to be called compound. 

Four fractures through or near 
the symphysis were nearly or quite 
vertical, and most of the others were 
known to be oblique. Malgaigne has remarked, also, that in fractures of 
the body of the bone the direction of the obliquity is generally such that 
the anterior fragment is made at the expense of the internal face of the 
bone, and the posterior fragment at the expense of the external face ; 
this latter overriding the former. Buck, of New York, has seen the 
fragments in an opposite condition, requiring the use of the knife and 
saw for their extrication. 1 I have myself recorded one similar example, 
but in which the fragments were easily replaced. 

In 28 examples of fractures through the body, not including fractures 
of the symphysis, the line of fracture has been observed to be 18 times 
at or very near the mental foramen, three times between the first and 
second incisors, four times behind the last molar, and three times be- 
tween the last two molars. 

Syme, Liston, and Miller have remarked, also, the greater frequency 
of fracture near the anterior mental foramen ; but Mr. Erichsen thinks 
he has seen it most frequently broken near the symphysis, between the 
lateral incisors, or between these teeth and the canine. Boyer observes 
that it is generally somewhat in front of the foramen ; for which reason, 
as he thinks, the dental nerve is rarely torn. 

Says Boyer, in his Traite des Maladies Chirui-gicales, " A fracture 



1 New York Journ. Med., March. 1847. Proceedings of N. Y. Med. and Surg. Soc, 
Sept. 19, 1846. 



122 FRACTURES OF THE LOWER JAW. 

never takes place in the central point of the length of the jaw, called 
the symphysis of the chin ; but when the solution of continuity occurs 
towards the middle of the bone, it is upon one or the other side of the 
symphysis, which remains always upon one. of the fragments." An 
opinion which, however, he does not seem always to have entertained, 
since Richerand, in a report of his lectures, has made him say that a 
fracture sometimes takes place " near the chin, but seldom so as to 
produce the division of the symphysis of that part, though it be not 
impossible." But many surgeons since his time have noticed this frac- 
ture, and Malgaigne assures us that J. Cloquet has demonstrated its 
existence upon an anatomical specimen. 

Stephen Smith, of New York, has seen two examples, 1 Lonsdale men- 
tions three, 2 and Gibson has seen one, 3 and I have met with two, both 
of which are recorded in the early editions of this book. 

Velpeau, Fergusson, Gibson, Henry Smith, and others, have remarked 
that a separation at the symphysis takes place usually in infancy or 
childhood. But in the eight examples in which I find the ages reported, 
only one, a case mentioned by Lonsdale, occurred in a person as young 
as ten years ; in one of the cases seen by myself the patient was 
seventeen years old, and the remainder have ranged from twenty -five 
years to sixty ; and the average age of all is thirty-two years. 

I have seen one example of a fracture of the ramus, in a man twenty- 
three years old, who had been struck by a wooden block on the side of 
his face. The ramus was broken just above the angle, and the body 
was broken, also, obliquely near the symphysis. The intercepted frag- 
ment was carried inwards ; 4 and in May, 18G9, I met with another 
similar case at Bellevue Hospital, in a woman ; a pharyngeal abscess 
resulted, threatening suffocation ; for which my house surgeon, Dr. 
Frank Bosworth, performed tracheotomy successfully. Ledran men- 
tions the case of a child, ten or twelve years old, in whom the fracture 
was double also ; one fracture having taken place through the body, 
and one extending obliquely from the root of the coronoid process to 
the neck of the condyle. The intercepted fragment was, however, so 
little displaced that the fracture of the ramus was not discovered. until 
after death. 5 Malgaigne refers to this as the only example recorded ; 
but Stephen Smith, of the Bellevue Hospital, has met with it four times : 
in one case the ramus was broken on both sides ; in two cases one ramus 
only was broken ; and in one the body was broken on the right side and 
the ramus on the left. 6 In two of these examples the fragments were 
not displaced. 

The coronoid process is so well protected by muscles and by the sur- 
rounding bony projections, that it is very rarely broken. 

Houzelot mentions a case in which a fall from a height produced at 

1 New York Journ. Med., Jan. 1857, Hospital Reports. 

2 Practical Treatise on Fractures. By Edward F. Lonsdale, London, 1838, p. 226* 

3 Institutes and Practice of Surg. By William Gibson. Philadelphia, 1841, p. 261. 

4 Trans. Arner. Med. Assoc. Report on "Deformities after Fractures," vol. viii. 
p. 385, Case 17. 

5 Malgaigne, op. cit., p. 337, from Ledran, Observ. Chirurg. torn. i. obs. vii. 

6 New York Journ. of Med., Jan. 1857. Bellevue Hosp. Reports. 



FRACTURES OF THE LOWER JAW. 123 

the same time a fracture of both condyles, of both coronoid processes, 
and of the symphysis. 1 

With this single exception, I am not able to find a recorded example 
of a fracture of this process. 

At least nine cases have been reported of fracture of the condyles, in 
all of which the separation occurred through the neck, viz., three by 
Ribes, two by Desault, one by Berarcl, one by Houzelot, one by Bichat, 
one by Packard, of Philadelphia, and two by Watson, of New York ; 
the fracture always occurring through the neck and just below the in- 
sertion of the external pterygoid muscle. 

According to Malgaigne, the analysis of these cases, excepting those 
mentioned by Packard and Watson, shows two classes of examples ; the 
one occasioned by falls or blows upon the chin, and producing a simple 
fracture of the neck of the condyle ; the other occasioned by injuries 
inflicted upon the side of the face, and producing a fracture of the neck 
on the side corresponding to that upon which the injuries are received, 
and at the same time a fracture of the body upon the opposite side. 
These two varieties seem to be about equally common. 

In the case mentioned by Houzelot, and already cited, there existed 
at the same time a fracture. of both condyles, of both coronoid processes, 
and at the symphysis. The man also whom Watson saw in the New 
York Hospital had fallen from the yard-arm of a vessel, breaking his 
thigh and arm bones and both condyles of the lower jaw. " His face 
was somewhat deformed by the retraction of the chin ; the mouth could 
not be opened so as to protrude the tongue to any great extent beyond 
the teeth, and the teeth of the upper and lower jaws could not be brought 
into contact. In attempting to move the jaw, the patient experienced 
pain and crepitation just in front of the ears ; the crepitation could easily 
be felt by placing the fingers over the fractured condyles. Nothing was 
done for the fractures of the jaw. In a few weeks the rubbing of the 
broken surfaces and attendant soreness ceased to trouble him ; but the 
shape of the jaw, and difficulty of opening the mouth to any great extent, 
still remained unaltered.'" 2 

Etiology. — The causes, in such cases as I have myself investigated, 
seem generally to have been direct blows, in most instances inflicted by 
a club, or by the kick of a horse ; in two examples the blow was inflicted 
by the fist. I have also seen a fracture immediately in front of the 
right cuspid, in a lad eight years of age, produced by being pressed be- 
tween two wagons, the pressure being made upon the two angles of the 
jaw. A case came under my notice at Bellevue, in 1879, in which a 
double fracture was produced in a young woman by the grasp of her 
husband's hand. In ten of eleven cases mentioned by Stephen Smith, 
the causes were direct blows. Examples of fracture of the inferior 
maxilla from indirect blows have, however, been mentioned by other sur- 
geons, the angles of the bone being pressed together by the passage 
of a wheel, and the fracture taking place usually toward the sym- 
physis. 

1 Malgaigne, op. cit., p. 400. 

2 New York Journ. of Med., Oct. 1840. Hospital Reports. 



124. FRACTURES OF THE LOWER JAW. 

We have already alluded to the observation of Malgaigne, that frac- 
tures of the condyles belong to two classes ; the one being occasioned 
by falls upon the chin, and the other by blows upon the side of the face ; 
the former acting as a counter force, and the latter as a direct. 
The coronoid process can only be broken by a direct blow. 
Symptoms. — Fractures of the body of the bone are characterized by 
the usual signs of fracture elsewhere, namely, displacement, mobility, 
crepitus, and pain. 

The displacement is generally present ; but its direction and amount 
vary according to the situation and course of the fracture, and also ac- 
cording to the violence and direction of the force producing the frac- 
ture. I have seen several cases 'unaccompanied with displacement, and 
one of these I think ought to be regarded as an example of a partial 
fracture. 

A lad, set. 9, was kicked by a horse on the 22d of June, 1858, the 
blow being received on the right side of the jaw. I saw him very soon 
after the accident, but could not detect any fracture, only the body of 
the jaw seemed to be bent in. On the third day, however, while en- 
deavoring to straighten the jaw by violent pressure from within out- 
wards, I detected a feeble crepitus, which on more careful examination 
proved to be opposite the second incisor of the right side. I was also 
able to detect a slight motion at the same point. It was found impossi- 
ble to rectify the bending, and no farther efforts were made. After the 
lapse of nearly a year, the natural curve was found to be partially, but 
not completely, restored. 

Ledran and other surgeons have also seen examples ivhere neither the 
periosteum nor mucous membrane was torn. 

Generally, in fractures of the body, the anterior fragment is depressed ; 
and Malgaigne affirms that where an overlapping occurs, the anterior 
fragment lies, generally, within the posterior ; a fact which he explains 
by the direction which the line of fracture usually takes, namely, from 
without, inwards and backwards, as we have already mentioned. In 
one instance reported by me to the American Medical Association, 
where the jaw was broken at the symphysis and also on both sides 
through the body, the central fragments were found, after about four 
weeks, lifted two lines above the lateral fragments, and also slightly 
carried backwards. 1 I have twice also met with examples in which the 
posterior fragments were inclined to fall inwards toward the mouth, a 
circumstance which seemed to indicate that the course of the obliquity 
was in a direction opposite to that which Malgaigne has observed to be 
most frequent. In each of these examples the jaw was broken upon both 
sides, by blows inflicted with a club, and the fractures were situated 
well back. 2 It is possible, however, that the position of the fragments 
was due rather to the direction and force of the impression than to the 
direction Of the line of fracture. 

As to the action of the muscles in the production of displacement, 
Boyer, S. Cooper, Erichsen, and Malgaigne have observed that their 

1 Trans. Amer. Med. Assoc, vol. viii. p. 380, 1855, Case 6. 

2 Ibid., Cases 1 and 10. 



FRACTUKES OF THE LOWER JAW. 125 

action upon the anterior fragment is greater in proportion as the frac- 
ture is nearer the symphysis, and less in proportion as it approaches 
the angle. So that in the former case the attempt to close the mouth 
is sometimes attended with a depression of the anterior fragment, causing 
a separation of the fragments at their alveolar margins ; while in the 
latter case the attempt to close the mouth forcibly is occasionally attended 
with separation of the fragments along the line of the base. 

While I am not prepared to deny the accuracy of these observations, 
it is proper to notice that Liston found the greatest displacement when 
the fracture was opposite the first molar ; and I must confess that the fact, 
as stated by Boyer and others, does not seem to admit of a satisfactory 
explanation, since the number, and consequently the power, of the muscles 
which act upon the anterior fragment from below is greater in proportion 
as the line of fracture is further back. These muscles, namely, the 
digastricus, the genio-hyoglossus, and the mylo-hyoideus, with several 
other muscles which act less directly, all tend to depress the anterior 
fragment, and in some slight degree to carry it backwards ; a direction 
which, indeed, it usually takes, and which it would probably always 
take if left alone to the action of the muscles. If the fracture has 
occurred through the angle, or at any point within the attachments of 
the masseter muscle, the action of those fibres of this muscle which 
remain connected with the anterior fragment will sufficiently explain the 
fact that it is not now so easily depressed below the level of the poste- 
rior fragment ; while the separation of the fragments along the line of 
the base, when an attempt is made to close the jaw forcibly, is probably 
due to the loosening and partial clislodgment of some of the molars, 
which, being pressed upwards, act as a pivot upon which the fragments 
are made to bend. 

Boyer affirms, also, that " the fractured portions are never deranged 
so that one overrides the other in the direction of their length ; for 
the action of none of the muscles of the lower jaw is parallel to the 
axis of that bone ; besides, its extremities are retained in the glenoidal 
cavities of the temporal bones." But this theory is too exclusive, since 
the fragments may have become displaced in any direction independently 
of the muscular action. Moreover, -the action of the muscles attached 
to the anterior fragment, although not parallel to the axis of the bone, 
does somewhat favor a displacement in this direction ; and the action of 
the pterygoid muscles upon the posterior fragment still further favors 
this form of displacement. 

An overlapping of the fragments in the direction of the axis is, in 
simple fractures, no doubt, exceptional, and in such examples as I have 
seen it was very trivial. It occurred in case "three" of my "Report," 
the fracture being near the mental foramen; in case "two," the fracture 
being just anterior to the last molar ; and also in case "six," w T here the 
bone had been broken through the centre of the body on both sides and 
through the symphysis ; but in neither case did the overlapping exceed 
two or three lines, and it was always easily overcome. 

The mobility of the fragments is not so striking in these accidents as 
in fractures of the long bones, yet it is generally sufficiently marked, 
and especially where the bone is broken upon both sides at the same 



126 FRACTURES OF THE LOWER JAW. 

time. If only one side is broken, both motion and crepitus will be 
most easily detected by lateral pressure upon the posterior fragment, 
which, being the smallest and the least supported by antagonizing 
muscles, will be found to be the most movable. If the fracture is upon 
both sides, mobility and crepitus will be most readily developed by 
seizing upon the anterior fragment and moving it gently up and down, 
while the finger rests upon the alveolus within the mouth. 

Sometimes a slight swelling or tenderness at some point of the dental 
arcade, or the loosening or complete dislodgment of a tooth, will indicate 
the point of fracture. 

Pain, especially when the fragments are moved, is here more constant 
than in most other fractures, owing perhaps, in part, to the superficial 
position of the bone, which renders the soft parts lying over it more 
liable to injury from the causes of fracture ; but also, in part, to the 
lesions which the inferior dental nerve may have suffered. It is, indeed, 
a matter of surprise that injury to this nerve does not oftener seriously 
complicate these accidents, coursing, as it does, through so large a por- 
tion of the angle and body of the bone. One might naturally suppose 
that its complete disruption would often occasion paralysis of those 
portions of the face to which it is finally distributed, and that its partial 
lesions and contusions would create, in many cases, the most acute and 
constant suffering. It is rare, however, that we have present an amount 
of pain which might not be attributed to a severe shock, or a slight 
strain upon its fibres. I have myself never seen any extraordinary 
suffering distinctly attributable to an injury of the dental nerve after 
fracture ; nor any degree of facial paralysis, except in the case to be 
hereafter described. Rossi relates a case in which convulsions followed 
this accident, and in which, as a final remedy, he proposed to expose 
and bisect the nerve ; and Flajani saw a patient, whose jaw had been 
broken, die in convulsions on the tenth day, the muscular contractions 
having commenced as early as the fourth day after the accident. The 
autopsy disclosed a rupture of the dental nerve, but no injury to the 
brain. 

Boyer explained the infrequency of severe injury to the dental nerve 
by the supposition that the " greater part of these fractures take place 
between the symphysis and the foramen by which this nerve comes 
out." An opinion which may be correct, but needs confirmation. I 
have seen the body or angle broken at points posterior to the mental 
foramen, and where the nerve lies within its bony canal, at least thirteen 
times, and in front of the mental foramen nine times ; at other times the 
point of fracture has not been noted with such accuracy as to enable me 
to say whether it was in front or behind the foramen. 

I suspect that a better explanation may be found in the fact that the 
fragments seldom overlap to any appreciable extent, and that even the 
displacement in the direction of the diameters of the bone is generally 
inconsiderable ; or, if it does exist, the fragments are easily and promptly 
replaced. 

If the displacement is sufficient to occasion a complete disruption of 
the nerve, some degree cf temporary paralysis in the portions of the 
face supplied by it must be inevitable ; and, perhaps this occurs oftener 



FRACTURES OF THE LOWER JAW. 127 

than it has been noticed, since, during the confinement of the jaw by 
dressings, it is not likely to be observed, and after the lapse of a few 
weeks it will probably cease altogether. 

Boyer remarks that when it is torn, " the square and triangular 
muscles of the chin are paralyzed. The skin of that part and the in- 
ternal membrane of the under lip preserve their sensibility, which it 
appears they owe to some threads of the portio dura of the seventh pair ; 
but the paralysis of these muscles does not prove of itself that the jaw 
is fractured." Boyer has, however, noticed this result but once, and 
then in a case where- the bone was broken upon both sides and the soft 
parts greatly contused. The triangular and square muscles were para- 
lyzed, in consequence of which there was a slight contortion of the 
mouth. A. Berarcl has also mentioned a case of vertical fracture occur- 
ring between the second and third molars, without displacement, which 
was accompanied with complete insensibility of the lip on the same side 
throughout the space comprised between the commissure and the median 
line, and between the free border of the lip and the chin. The paralysis 
disappeared after a few days. 1 

At my request, Dr. Frederick S. Dennis, junior assistant at Bellevue 
Hospital, has furnished me with the following account of a case lately 
presented in one of my wards. I shall take the liberty of condensing 
somewhat the very full and interesting history which he has furnished 
me ; remarking, however, that the observations are all the result of his 
own careful investigation. 

Kate Campbell, aet. 30, was admitted, December 11, 1874, suffering 
from an attack of acute tonsillitis. I subsequently opened an abscess in 
the tonsil, and she was soon discharged cured. While taking notes of 
her case, Dr. Dennis learned the following facts. More than a year 
before she had received a fracture of the lower jaw, right side, and a 
distinct callus remained near the angle of the jaw to indicate the point 
at which the fracture had occurred. Since that time there has existed 
complete insensibility of that portion of the face which is supplied by 
the inferior dental nerve and its branches. Careful experiments were 
made with different substances, and with sharp instruments, all of which 
indicated "that the nerve was destroyed in the immediate vicinity of the 
dental foramen. The gustatory nerve, as well as the chorda tympani 
from, the facial, maintained their full physiological functions, both in 
reference to general sensation, and the special sense of taste. The 
mylo-hyoid branch of the inferior dental, which is given off just before 
the nerve enters the dental foramen, and which is motor in action, was 
not in the least impaired." Over the entire region supplied by the in- 
ferior dental nerve there was complete anaesthesia. Pins, thrust through 
the integument into the buccal cavity, caused no sensation. " The gums 
as well as the teeth, on the side corresponding to the fracture, were in a 
state of analgesia." 

The case above described furnishes an example of permanent paral- 
ysis of the inferior dental nerve, from fracture; and upon this point the 
following comments made by Dr. Dennis, are of special interest: — 



1 Malgaigne, from Gazette cles Hopitaux, 10 Aout, 1841. 



128 FKACTURES OF THE LOWER JAW. 

" Hemorrhage into the dental canal, or a slight laceration of the in- 
ferior dental nerve, with little displacement of the fragments, may cause 
a paralysis, which, in the former case after absorption, and in the latter 
case after repair of nerve-tissues, eventually terminates in complete 
recovery; but in the case under consideration there is no hope of the 
restoration of the function of the nerve, as too long a time has intervened, 
according to the views of the most sanguine neurologists. 

"Malgaigne has never seen a case of total destruction of the inferior 
dental nerve, in which permanent paralysis followed, from a fracture of 
the lower jaw. He believes the severe pain, which frequently occurs, 
to be due to cerebri tis rather than to injury of this particular nerve. 
He further states, in his work on Fractures, that the cases in which the 
nerve is injured, even in a slight degree, are very rare. 

"Petit, Rossi, Flajani, Foucher, Robert, and many other writers on 
this subject, give examples where the paralysis was of short duration ; 
and they say that they have never seen a case where the paralysis re- 
mained permanent. The only cases that can be found, in the researches 
that have been made, where the paralysis w T as permanent, is one re- 
ported by Desirabode in the Journ. des Connaissances, 1857, No. 20, p. 
538 ; and in this case the symptoms of injury of the inferior dental 
nerve are identical with those found in the case of Kate Campbell. The 
paralysis, in the case which Desirabode reports, was caused by a crude 
dental instrument, which tore the alveolar processes of seven teeth, and 
exposed the dental canal." 

To these signs now enumerated, we may add as occasional complica- 
tions, rather than as diagnostic symptoms, salivation, swelling of the 
submaxillary and sublingual glands, abscesses, necrosis, etc. If the 
blow has been vertical upon the chin, and the direction of its force has 
been toward the articulations, the bony structure of the ear, and even 
the brain, may have suffered serious lesions, which may be indicated by 
a deafness or a roaring in the ears, by bleeding from the external meatus, 
and by fatal coma. Tessier saw a man who had received the kick of a 
horse exactly upon the centre of the chin, breaking the bone on both 
sides, and w 7 ho, in consequence, bled freely from his ears; 1 and Alix 
relates the case of a young man who, falling from a height and striking 
upon his chin, had broken his jaw. Insensibility immediately followed; 
convulsions also ensued upon the fourth day, and he died upon the sixth. 2 

If the fracture is at the symphysis, it is generally vertical, and either 
fragment may be found slightly displaced upwards or downwards. In 
one of the examples seen by myself, the left fragment fell three lines 
below the right, and in another the right side had fallen about one line. 
In a case mentioned by Syme there was scarcely any displacement. 3 
Liston remarks that it is usually slight. Erichsen and B. Cooper have 
observed the same. 

The signs which indicate a fracture through the angle have already 
been sufficiently considered when speaking of fractures of the body; 

1 Malgaigne, pp. 383 and 386, from Journ. de Med. 1 , 1789, torn, lxxix. p. 246. 

2 Ibid., p. 386, from Alix, Observata Chir., fascic. 1, obs. 10. 

3 Amer. Journ. Med. Sci., vol. xviii. p. 243. 



FRACTURES OF THE LOWER JAW. 129 

from which it only differs in the less degree of displacement, and in the 
fact that the posterior fragments are a little more prone to fall inwards 
toward the mouth. I have noticed, also, that, owing probably to the 
loosening and partial dislodgment of the last molar, it is sometimes diffi- 
cult to close the mouth, the same as in the fractures a little farther for- 
wards. 

In each of the two examples of fracture of the ascending ramus which 
I have seen, the bone being broken also through its body, the fracture 
of the ramus was recognized by both crepitus and mobility. 

As to the signs which indicate a fracture of the coronoid process, I 
am only able to infer them from its anatomical relations. There must 
be some embarrassment in the motions of the jaw, occasioned by the 
detachment of a portion of the fibres of the temporal muscle ; and it is 
probable that an examination by the finger within the mouth would readily 
detect mobility and displacement. 

A fracture through the neck of the condyle is characterized by pain 
at the seat of fracture, especially recognized when an attempt is made to 
open or shut the mouth, by embarrassment in the motions of the jaw, by 
crepitus, which may usually be felt or heard by the patient himself, by 
mobility and displacement. 

The upper fragment, if disengaged from the lower, is drawn forwards, 
upwards, and inwards, by the action of the pterygoideus externus ; and 
it is felt not to accompany the movements of the lower fragment. 

The lower fragment is at the same time drawn upwards, in consequence 
of which the lower part of the face is distorted ; a circumstance first 
noticed by Ribes, and which supplies an important diagnostic mark be- 
tween a fracture of one condyle and a dislocation. In dislocation, the 
chin is commonly thrown to one side, but it is to the side opposite that 
on which the dislocation has occurred, while in fracture the chin is drawn 
to the same side. 

Prof/nosis. — Physick, of Philadelphia, saw a case of non-union of the 
body of this bone, which had existed nine months. 1 Dupuytren mentions 
a case which had existed three years. 2 Stephen Smith, of New York, 
reports a case of fracture of both the body and the*ramus, in a man forty- 
five years old. The severity of the injury, with the supervention of 
delirium tremens, prevented the application of dressings until the thir- 
teenth day. On the twentieth day, about a pint of blood was lost by 
hemorrhage from the seat of fracture. He remained in the hospital one 
hundred and thirty-seven days, and was finally discharged, the fragments 
not having yet united. 3 I have seen four examples of fibrous union. In 
Dr. Muhlenberg's tables sixteen examples are enumerated out of a total 
of six hundred and fifty-six cases of non-union and delayed union. 4 In 
no instance of a simple fracture which has come under my personal care 
from the first, has the bone refused finally to unite, although I have seen 
the union delayed six, seven, ten, and even eleven weeks or more. 5 In 

1 Phila. Med. and Surg. Journ., vol. v. 2 Lecons Orales. 

3 Smith, New York Journ. of Med. and'-Surg., Jan. 1857. 

4 Agnew's Surg., op. cit., vol. i. p. 804. 

5 My Report on Deformities after Fractures, Cases 2, 14, 15, 18. 



130 FKACTURES OF THE LOWER JAW. 

three of these cases the fractures were either compound or comminuted ; 
but in one case the fracture was simple, the delay in the union being due 
to a feeble condition of the system, and in part, perhaps, to neglect of 
proper treatment. Since the commencement of the late war I have met 
with several examples of non-union, and of fibrous union, after gunshot 
fractures ; but, so far as I can remember, in all of these cases necrosis 
existed, or some portions of the bone had been carried away. 

The infrequency of non-union after this fracture is a fact worthy of 
especial attention, because of the extreme difficulty, if not actual im- 
possibility, in many cases, of wholly preventing motion between the 
fragments, by any mode of dressing yet devised. Any one who has 
observed attentively, must have seen, not only that his dressings are more 
often found disturbed and loosened than in the case of almost any other 
fracture, unless it be the clavicle, and thus the fragments have been 
through all the treatment subjected to frequent changes of position ; but, 
also, that even while the dressings remain snugly in place, the patient 
seldom is able to perform the necessary acts of deglutition, or to speak, 
even, without inflicting some slight motion upon the fragments. 

Indeed, the rapidity as well as certainty with which this bone unites, 
has, I think, been observed by other surgeons, and I have myself noticed 
one instance, in an adult person, in which the bone was immovable at the 
seat of fracture on the seventeenth day, and perhaps earlier. In other 
instances, the union has been speedily effected after the removal of all 
dressings. 

The amount of deformity resulting, also, from these fractures is usually 
very trifling, whatever treatment has been adopted. Only nine of the 
united fractures, seen and recorded by me, are imperfect, and in none 
of these is the imperfection such as to be noticed in a casual examination 
of the face. The deformity which is usually found, is a slight irregu- 
larity of the teeth, produced, in most cases, by a falling of the anterior 
fragment, but in one case by a slight elevation of the anterior fragment. 
But even this does not always interfere with mastication, and would often 
pass unnoticed by the patient himself. It is probable, too, that time, and 
the constant use of the lower jaw in mastication, will gradually effect a 
marked improvement in the ability to bring the opposing teeth into con- 
tact. I think I have observed this in several instances. 

In a letter dated Sept. 30, 1876, Dr. John H. Packard, of Philadel- 
phia, informs me that in a case of fracture of the lower jaw, occurring 
near the left anterior mental foramen, the right fragment was so forcibly 
displaced downwards, by the action of the muscles, that he was obliged 
to sever their attachments at the symphysis, in order to retain the frag- 
ments in place. 

Chelius remarks that in " double or oblique fractures it is very diffi- 
cult to keep the broken ends in their proper place ; deformity and dis- 
placement of the natural position of the teeth commonly remain." 

In the second example of fracture through the symphysis mentioned 
by me, the left fragment remained slightly elevated, and the patient could 
not close his teeth perfectly, yet he could close them sufficiently for the 
purposes of mastication. It is probable, however, that ordinarily no 



FRACTURES OF THE LOWER JAW. 131 

difficulty will be experienced in accomplishing a perfect cure when the 
separation has taken place only at the symphysis. 

In fractures of the condyles, more care is requisite to retain the frag- 
ments in apposition, and sometimes it may be found to be impossible. 
Richerand mentions the case of a man, who, having been three months 
in the " Hopital de la Charite," for a double fracture of the lower jaw, 
one fracture being near the middle, and the other near the right con- 
dyle, left before the cure was complete. Seven or eight months after, 
he called upon Boyer, who extracted, from a fistula in the meatus audi- 
torius externus, a bony mass which had evidently the form of the con- 
dyle. 1 Bichat mentions a similar case as having come under the obser- 
vation of Desault ; 2 possibly it was the same which Boyer saw. Ribes 
says that a Parisian surgeon treated a double fracture of the jaw in a 
gentleman, one fracture being through the body and the other through 
the neck of the condyle ; and, in spite of the most assiduous and skilful 
attention, the patient recovered with a lateral distortion of the jaw, 
occasioned by the displacement of the fragments. 3 Ribes himself had 
to treat an accident of a similar character, and, notwithstanding all his 
care, the result was the same as in the other example just cited. 4 Foun- 
tain, of Iowa, was much more fortunate, having made a complete and 
perfect cure. 5 

The proximity of this fracture to the articulating surface may occa- 
sion contraction of the ligaments about the joint ; and a degree of em- 
barrassment to the motions of the jaw has followed in the experience of 
Desault and others, even when the cure has been" most complete ; but 
this has usually remained only for a short period. 

Sanson asserts that when the coronoid process is broken, the fracture 
never unites ; but that mastication is performed very well, the masseter 
and pterygoid muscles then fulfilling the office of the temporal. 6 

Treatment.— -The few attempts which I have made to restore a com- 
pletely dislocated tooth to its socket, or to retain it in place when very 
much loosened, have generally resulted in its removal at some later day, 
and especially where the fracture has been near the angle and a molar 
has been disturbed. I believe it would be better practice always to 
remove the molars under these circumstances, unless they remain at- 
tached to the alveoli, and cannot be removed without bringing them 
away also ; and this, whether the loosened teeth are situated in the line 
of fracture or not. It is seldom that they can be made again to occupy 
their sockets perfectly, and where the teeth are in the line of the frac- 
ture, the attempt to restore them to place will sometimes prevent the 
proper adjustment of the fragments. In cases, also, in which the teeth 
farther forwards are completely dislodged at the seat of fracture, it is 
scarcely worth while to replace them. 

As to those teeth whose loosened condition is due only to a splitting 
of the alveoli in a longitudinal direction, the same rule will not always 

1 Boyer, Lectures on Dis. of Bones, p. 53, Phila. ed., 1805. 

2 Desault, Treatise on Fractures and Luxations, Phila. ed., 1805, p. 3. 

3 Malgaigne, op. cit., p. 402. 4 Ibid., p. 402. 

5 Fountain, New York Journ. Med., Jan. 1860. 

6 S. Cooper's First Lines, Amer. ed., 1844, vol. ii. p. 311. 



132 FRACTURES OF THE LOWER JAW. 

apply. Sometimes, after a careful readjustment, the fragments will re- 
unite, and the teeth remain firm. 

If the bone is chipped off upon the outside, through or near the line 
of the sockets, the teeth may not be always much disturbed, and the 
loss of the fragments may be of less consequence, nor have I generally 
succeeded in saving them ; yet if they remain adherent to the soft parts, 
it is proper to make the attempt. 

The expedients to which surgeons have resorted for the purpose of 
retaining in place the fragments, when the bone is broken through its 
body, may be arranged under the names of ligatures, splints, bandages, 
and slings. 

The ligature has been applied both to the teeth and to the bone itself. 
Thus, in an oblique fracture near the angle, where the fragments could 
not otherwise be prevented from falling inwards, Baudens passed a strong 
ligature, formed of thread, around the fragments and in immediate con- 
tact with them, tying the ligature over the teeth within the mouth. No 
accident followed, and on the twenty-third day, when he removed the 
ligature, the bone had united firmly and smoothly. 1 

In the case of the fracture of the inferior maxilla, reported by Dr. 
Buck to the New York Pathological Society, and already referred to, 
the bone "was broken between the two incisor teeth of the left side; 
the part of the bone on the left of the fracture was driven in, and in- 
terlocked behind the end of the right portion, so as to be separated by 
a finger's breadth. Finding it impossible otherwise to reduce the frac- 
ture, Dr. B. dissected off the under lip, so as to expose the fracture. 
He found that the right anterior portion of the fractured bone termi- 
nated in an angular projection as far as on a line below the left angle 
of the mouth. The lip was then divided to the chin, and the soft parts 
holding the fragments together incised. A chisel was then insinuated 
behind the projecting angle of the bone, while it was being excised 
by the metacarpal saw;. When the bone was restored to its natural 
position, it was found so apt to become displaced, that holes were drilled 
at the lower angle of the fracture, and adjustment maintained by wiring 
them together, the wire passing out through the lower angle of the 
wound. Sutures and adhesive straps, with a bandage, were employed 
to maintain the adjustment of the parts. So far the patient has done 
well, being supported by liquid nourishment introduced through a tube 
passed through the space left by one of the incisors, which, on account 
of its looseness, was removed." 2 Dr. R. A. Kinloch, of Charleston, 
S. C, has reported a similar case, in which he employed successfully 
the wire. 3 

In May, 1858, while trephining at the angle of the jaw for the pur- 
pose of cutting out a portion of the dental nerve in a patient suffering 
from neuralgia, I accidentally broke the jaw in two at the point at which 
the trephine was applied. I immediately bored a hole in the opposite 
extremities of the two fragments, and fastened them together with a 

1 Malgaigne, op. cit., p. 398. 

2 New York Journ. of Med., etc., March, 1847, p. 211. 

3 Kinloch, Am. Journ. Med. Sci., July, 1859, p. 67. 



FRACTURES OF THE LOWER JAW. 133 

silver wire, by which I was able to maintain complete apposition, and in 
three weeks the union was accomplished, the wire separating and falling 
out of itself. No splints were ever used. 1 

James O'Neill, set. 38, received a fracture of the inferior maxilla on 
the right side, between the second bicuspid and second molar. He came 
under my notice May 5th, nearly three months after the accident oc- 
curred. The fragments w r ere united with a fibrous band, and with a 
good deal of displacement. I sent him to a dental infirmary, but the 
efforts to replace and retain the fragments, made by the gentleman in 
charge, were unsuccessful, and on the 20th of June folloAving I operated, 
by making an external incision to the point of fracture, exposing the 
bone thoroughly, and, having freshened the broken surfaces, the frag- 
ments were perforated and secured in apposition with a silver wire. 
Aug. 12th the ligature was removed, a bony union being effected with 
but little displacement. 

My experience has been that the perforations must be made perpen- 
dicularly, not obliquely, through the fragments, and some distance from 
their margins ; and that to withdraw the wire or to return it from within 
outwards, an instrument with a straight shaft, rather smaller than the 
perforation, and furnished with an abruptly curved, blunt extremity, is 
required. The wire should be large, strong, and flexible, and the perfo- 
ration should be twice as large as the wire. The instrument and method 
devised by Mr. Thomas, Liverpool, in 1863, and reprinted in Kingsley's 
w T ork on Oral Deformities, is not satisfactory. 

Ordinarily the ligature has been employed only as a means of reten- 
tion, by fastening it upon the teeth, either upon those which are situated 
on the opposite sides of the fracture, or upon others a little more remote, 
or upon the corresponding teeth of the upper jaw, or upon the teeth on 
the opposite sides of the same jaw. 

In most cases the ligature, composed of either fine gold, platinum, or 
silver w T ire, or firm silk or linen threads — (Celsus advised the use of 
horsehair) — has been applied to the two teeth on the opposite sides of 
the fracture, or if these have not been sufficiently firm, to the next teeth. 
This practice, recommended first by Hippocrates, has received the occa- 
sional sanction of Ryfif, Walner, Chelius, Lizars, Erichsen, Miller, B. 
Cooper, Skey, and others, but by Boyer, Gibson, and Malgaigne it has 
been disapproved. 

Dr. S. G. Ellis, of New York, as we have already seen, has treated 
a fracture, occurring through the symphysis, in an adult, by placing the 
mainspring of a watch within the dental arcade, and securing it in place 
with silver w T ire. The mouth was kept closed by bandages carried under 
the chin. The fragments united Avith only a slight vertical displacement. 2 

Dr. George Hayward, of Boston, surgeon to the Massachusetts Gen- 
eral Hospital, says : " When the bone is not comminuted and there are 
teeth on each side of the fracture, the ends of the bone can be kept in 
exact apposition by passing a silver wire or strong thread around these 
teeth and tying it tightly. In several cases of fracture of the jaw, in 

1 Buffalo Med. Journ., vol. xiv. p. 148. 

2 Trans. Amer. Med. Assoc. My Report on " Defor.," etc., vol. viii. p. 383, Case 14. 



134 FRACTURES OF THE LOWER JAW. 

which the bone was broken in one place only, I have, in the course of 
the last few years, adopted this practice with entire success, and without 
the aid of any other means. It will be found very useful, also, as an 
auxiliary, in more severe cases, in which it may be required to use splints 
and bandages, or to insert a piece of cork between the jaws, as recom- 
mended by Delpech. It requires some mechanical dexterity to apply 
the thread neatly ; but in large cities we can avail ourselves of the skill 
of dentists for this purpose." 1 I have myself in two or three instances 
used a linen thread with excellent results. 

Guilio Saliceto advises to secure with a silk thread, at the same mo- 
ment, the teeth belonging to the two fragments, and the corresponding 
teeth of the upper jaw; 2 while the dentist Lemaire, being applied to by 
Dupuytren to secure in place the ununited fragments of a broken jaw, 
fastened the two left canine teeth/to each other by a wire of platinum, as 
had been already suggested by Guilio Saliceto ; to those he added two 
other modes of ligature which were altogether original. One wire, 
fastened to the last molar upon one side, traversed the mouth and was 
secured to one of the bicuspids upon the opposite side ; the other was 
stretched from the first inferior bicuspid on the right to the first superior 
bicuspid on the left. A cure was accomplished at the end of two months, 
but one of the wires had nearly bisected the tongue ; and as it had 
gradually become imbedded, the flesh had closed over it until it rested 
like a seton through the middle of the tongue. 3 

None of these various methods, however, will in general be found to 
possess much value ; for besides that they are all of them, in a large 
majority of cases, wholly unnecessary, and in other cases, owing to the 
absence of the teeth, or to their loosened or decayed condition, or t6 
the closeness with which they are set against each other, absolutely im- 
possible, it must be seen, also, that they will generally prove feeble and 
inefficient. The wires act only upon the upper extremity of the line of 
fracture, leaving its lower portion liable to be disturbed by trivial causes; 
they tend gradually to loosen even the firm teeth which they embrace, 
and not unfrequently, after having been made fast with much labor, they 
soon become disarranged or break. They require, therefore, almost 
always the additional protection afforded by bandages, interdental splints, 
etc. Alone they are usually insufficient, and if properly constructed 
bandages, slings, interdental splints, etc., are employed, they are not 
needed. Sometimes, moreover, they are actually mischievous, as when 
they loosen a sound tooth or press upon and inflame the gums. A. Be'- 
rard passed a silver wire twice around the necks of two adjoining teeth 
on the opposite sides of a fracture. It retained the fragments perfectly 
in apposition during several days ; but soon the gums swelled and be- 
came painful ; the teeth loosened, and it was found necessary to remove 
the wire. Chassaignac sought to avoid these evils by placing the wire 
upon the middle of the crown, free from the gums, and by including four 
teeth instead of two. A waxed linen thread was made fast in this man- 



1 Boston Med. and Surg. Journ., vol. xix. p. 133, 183b. 

2 Malgaigne, op. cit., p. 392. 

8 Journ. Univer. des Sci. Med., torn. xix. p. 77. 



FRACTURES OF THE LOWER JAW. 135 

ner, in a case of simple fracture, on the seventh, day. On the following 
morning the thread was found broken. He applied then a silk ligature 
in the same manner. On about the third day this also was disarranged ; 
the ligatures were now discontinued until the eighteenth day, when he 
renewed the experiment with a piece of gold wire. Fourteen days after 
this the ligature remained firm, but the gums were red and bleeding. 
The patient not having again returned to Chassaignac, the result is not 
known. 1 

As to the method suggested by Guilio Saliceto, it presents no advan- 
tages to compensate for its inconveniences ; while that actually practised 
by the dentist Lemaire, successful indeed, threatened to substitute a loss 
of the tongue for an ununited fracture of the jaw. 

Splints have been employed in various ways. First, simply inter- 
dental splints, laid along the crowns of the teeth, and only sufficiently 
grooved to be easily retained in place ; second, clasps, which are applied 
over the crowns and sides of the teeth, operating chiefly by their lateral 
pressure, or made fast by screws ; third, splints applied to the outer and 
inferior margin of the jaw ; fourth, interdental splints combined with 
outside splints. 

Interdental splints have been recommended by many surgeons from 
an early day, and they continue to be employed occasionally up to this 
moment. 

Boyer advises the use of cork splints, placed one on each side between 
the upper and lower jaws, in a few exceptional cases. Miller recom- 
mends the same in all cases, the " two edges of cork sloping gently back- 
wards, with their upper and under surfaces grooved for the reception of 
the upper and lower teeth." Fergusson also has usually adopted the 
same practice. Muys and Bertrandi employed ivory wedges. 2 

On the other hand, interdental splints are rejected entirely by Syme, 
Chelius, Skey, Erichsen, and Gibson. 

The objections which have been stated to their use are : that they are 
unsteady and become easily loosened and disarranged ; that they occa- 
sionally press painfully upon the inside of the cheeks ; that they accu- 
mulate about themselves an offensive sordes ; and finally that they are 
unnecessary, since experience has proven, says Gibson, that " there is 
always sufficient space between the teeth to enable the patient to imbibe 
broth or any other thin fluid placed between the teeth." 

It is not strictly true, however, that in all cases there will be found 
sufficient space between the teeth, when the mouth is closed, for the im- 
bibition of nutrient fluids. I have myself seen exceptions ; and in such 
a case the patient, if the mouth were closed in the usual way, would 
have to be fed through a tube conveyed along the nostrils into the stom- 
ach, as suggested by both Samuel and Bransby Cooper in certain bad 
compound fractures, or through an opening made by the extraction of 
one of the front teeth ; neither of which methods ought to be preferred 
to the interdental splints ; but then the separation of the front teeth for 
the purpose of receiving food, is by no means the only object to be 

1 Lond. Med. and Phys. Joarn., Nov. 1822, p. 401. 

2 Lond. Med. Chir. Rev., vol. xx. p. 470. 



136 FRACTURES OF THE LOWER JAW. 

gained by their use, nor indeed the principal object. Their great pur- 
pose is to act as splints whenever the absence of teeth, either in the 
upper or lower jaw, renders the two corresponding arcades unequal and 
irregular, and prevents our making use of the upper as a kind of internal 
splint for the lower jaw. 

It is with a view to the accomplishment of this important end that 
they are often valuable, and ought sometimes to be considered as indis- 
pensable. I believe also, that many of the inconveniences which have 
been found to attend the use of cork or wood, are obviated by the sub- 
stitution of gutta percha in the manner which I recommended to the 
profession in 1849, * and also again in my report to the American Medical 
Association, made in the year 1855. 

The mode of preparing gutta percha, and of adapting it between the 
teeth, is as follows : Dip a couple of pieces of the gum, of a proper size, 
into hot water ; and when they are softened, mould them into wedge- 
shaped blocks, and carry them to their appropriate places between the 
back teeth on each side of the mouth ; taking care, of course, that on 
the fractured side the splint extends sufficiently far forwards to traverse 
thoroughly the line of fracture. Now press up each horizontal ramus 
of the jaw until the mouth is sufficiently closed, and the line of the in- 
ferior margin is straight ; in this position retain the fragments a few 
minutes, until the gum has well hardened. Meantime it will be prac- 
ticable, generally, to introduce the fingers into the mouth, and to press 
the gutta percha laterally on each side toward the teeth, and thus to 
make its position more secure. When it is hardened, remove the splints, 
for the pupose of determining more precisely that they are properly 
shaped and fitted. 

It is scarcely necessary to say that in carrying the long wedge-shaped 
block into the mouth, the apex of the wedge is to be introduced first. 

The superiority of this splint is now at once perceived. If properly 
made, it is smooth upon its surface, and not, therefore, so liable to irri- 
tate the mouth as wood or cork, and it is so moulded to the teeth that it 
will never become displaced. It possesses this advantage, also, that 
in case more or less of the teeth are gone in either the upper or lower 
jaw, it fills up the vacancies, and renders the support uniform and steady. 

The "• clasp," applied over the crowns and sides of teeth, is not in- 
tended to act as an interdental splint ; but by its lateral pressure it is 
expected to hold the fragments in apposition upon nearly the same prin- 
ciple with the ligature. 

Miitter, of Philadelphia, and N. R. Smith, of Baltimore, employ for 
this purpose a plate of silver, folded snugly over the tops and sides of 
two or more teeth adjacent to the fracture. 

Nicole, of Nuremberg, employed for the same purpose a couple of 
steel plates fitted accurately along the anterior and posterior dental cur- 
vatures, secured in place by a steel clasp, the clasp being furnished with 
a thumb-screw, in order the more effectually to accomplish the lateral 
pressure. 

Malgaigne has extended the idea of Nicole, by substituting for the 

1 Buffalo Mod. and Surg. Journ., vol. v. p. 144, Aug. 1849. 



FRACTUKES OF THE LOWER JAW. 137 

two steel plates a single plate composed of flexible and ductile iron, 
which is fitted accurately to all the irregularities of the posterior dental 
arch. From the two extremities of this plate, and from two other inter- 
mediate points, four small steel shafts arise perpendicularly, cross the 
crowns of the teeth at right angles, and then fall clown again perpen- 
dicularly upon the anterior dental arcade. Each steel shaft being fur- 
nished with a thumb- screw, the iron plate can now be made to bear 
against the teeth so as to form a posterior dental splint. The teeth are 
also protected in front against the direct action of the thumb-screw by 
the interposition of a leaden plate. 

J. B. Gunning, dentist, of New York, substituted for all these mate- 
rials vulcanized India-rubber, which he employs both as a clasp and as 
an interdental splint ; and, according Dr. Covey, 1 the same material 
has been used with excellent results by J. B. Bean, dentist, of Atlanta, 
Ga. The following in Dr. Bean's plan of procedure. 

An impression is taken in wax of the crowns of the teeth of the unin- 
jured jaw,. and of each fragment separately of the broken jaw. When, 
in doing this, the ordinary " impression cup" used by dentists cannot be 
introduced, one composed of a thin metallic plate, which is covered with 
wax and stiffened by a rim of wire, may be substituted. 

" From these impressions are made casts of plaster of Paris, very 
carefully prepared, so as to produce a smooth, hard surface, and giving 
as perfect a representation of the teeth as possible. These plaster 
models are then adjusted, properly antagonized in their normal position, 
and placed in the ' maxillary articulator.' 

" The fragments of the model representing the broken jaw are held 
in their proper position by wax, being secured thus one to the other, and 
to the remaining plate of the artic- 
ulator." . . . The model jaws are Fig. 27. 
now opened from three to five lines, 
and a wax model of a splint is built 
up between the molars, covering 
also the inner and outer surfaces 
of the teeth. A connecting band 
of wax is laid from one side to the 
other behind the upper front teeth, -A 
leaving thus an opening in front ■ 
for the reception of the food. This ^ 

Wax and plaster model, nOW COm- Maxillary Articulator. 

posing one piece, is then removed i, 1. u PP er and lower plates. 

£ Yi .• i . ii i • 2, 2. Adjustable rods. 

trom the articulator, and placed in 3j 3 . Adjustable hinge. 

a dentist's "flask," and a com- 
plete mould of the model is again formed from plaster laid on in sections, 
in a manner which those accustomed to make plaster moulds will readily 
understand. The plaster having fairly set, the flask and mould are 
opened, the wax carefully removed, and the spaces thus left in the mould 
at once filled with the rubber rendered soft by heat. The mould is again 
closed, replaced in the flask, and by heat the rubber is thoroughly vul- 

1 Bean, Richmond Med. Journ., Feb. 1866. 
10 




138 



FRACTURES OF THE LOWER JAW 



Fig. 28. 



canized. The flask is again opened, the plaster removed, and an inter- 
dental splint of rubber remains, which is fitted accurately to all the 
surfaces of the teeth both above and below. 

The splint is now placed in the mouth, adjusted to the teeth, and the 
lower jaw secured in position by the apparatus represented in the ac- 
companying woodcut. 

Dr. Covey says, that during the late war Dr. Bean was placed in 
charge of a hospital at Macon, Georgia, devoted exclusively to the re- 
ception of this class of injuries, and that over forty cases were treated, 
and with eminent success. 

My own judgment of this apparatus is, that so far as the substitution 
of vulcanized rubber for gutta percha is concerned, it is wholly unneces- 
sary in the great majority of simple fractures of the jaw. Gutta percha 
is applied with great facility, and with equal accuracy to all the dental 
surfaces, and it speedily hardens sufficiently for all practical purposes. 

In gunshot fractures, however, and in certain other badly commi- 
nuted fractures, I can well understand how the surgeon may advanta- 
geously avail himself of vulcanized rubber, which being someAvhat harder 
may be made to grasp the teeth attached to the several fragments more 

firmly ; and indeed may, in a few cases, 
allow of the teeth being made fast to 
the splint by screws. 

It will be observed that these are 
the cases which Dr. Bean has had 
chiefly under treatment. 

An examination of the cases re- 
ported by Dr. Covey will also show 
that the apparatus was never applied 
earlier than the tenth day, even when 
the patients were under the charge of 
Dr. Bean from the first, and that in 
most cases the application of the appa- 
ratus was delayed to a much later 
period. Indeed, it is apparent that 
there may be the same reasons for 
occasional delay in the application of 
vulcanized rubber as in the application 
of gutta percha, or any other mode of 
support and dressing. 
In reference to the head apparatus, or sling, as used by Dr. Bean, we 
have only a single remark to make. It is a modification of the appa- 
ratus employed for many years by myself — the modification consisting 
in the use of a horizontal piece of wood supporting a cup which is placed 
under the chin, the purpose of which is to prevent the lateral pressure 
usually made by the maxillary bands. The necessity of avoiding lateral 
pressure in certain cases, has long been recognized by myself and others ; 
and it has been found to be especially important in all comminuted and 
gunshot fractures. To the attainment of this purpose, I have employed 
usually a firm gutta-percha splint under the chin, to the projecting late- 
ral extremities of which the maxillary bands have been attached ; and I 




Bean's apparatus for broken jaw, applied. 



FRACTURES OF THE LOWER JAW. 139 

think it much better than Dr. Bean's piece of wood. In a great majority 
of cases, however, occurring in civil practice, that is to say, in most 
simple fractures, this submental splint is unnecessary, since the lateral 
pressure is harmless, especially when the interdental splints of gutta 
percha or of vulcanized rubber are employed. 

In short, while I am prepared to admit that Dr. Bean has by his 
appareil, and by the application of great mechanical skill, talent, and 
industry, treated successfully many cases which by other appliances and 
in other hands might have resulted most unfortunately, yet it is plain 
that his method will find its field of usefulness in civil practice limited to 
exceptional cases. 

Dr. J. S. Prout, of Brooklyn, New York, has suggested to me a very 
ingenious mode of employing the interdental splint and wire ligature 
conjointly, and which method, at my request, he adopted recently in a 
case under my care at Bellevue Hospital. A plate of gutta percha was 
placed upon the top of the teeth across the line of fracture, and this was 
secured in position by silver wire, which had been made to grasp firmly 
the crowns of the adjacent teeth, and was then brought over the horizontal 
gutta-percha plate. In this case it accomplished all that was desired. 

External splints, applied along the base or outside of the jaw, were 
first recommended by Pare', who used for this purpose leather ; and 
they have been employed in some form, occasionally, by most surgeons. 
Generally they have been composed of flexible materials, such as wetted 
pasteboard, first recommended by Heister, felt linen saturated with the 
whites of eggs, paste, dextrin, or starch ; plaster of Paris has also been 
used ; and they have been retained in place by either bandages or the 
sling. As before stated, I have myself used for this purpose gutta 
percha, but I shall speak of it as one form of the sling dressing. 

Undoubtedly useful, and even necessary in some cases, especially 
where there exists a great tendency to a vertical displacement, they will 
be found, also, in many cases, to render no essential service, and may 
properly enough be dispensed with. 

Whatever objections hold to the use of metallic clasps, must apply 
in some degree to the use of those forms of apparatus in which it is 
attempted to secure the fragments by means of a combination of these 
clasps with outside splints, and in which it is proposed to dispense with 
all bandages or slings, the mouth being permitted to open and close 
freely during the whole treatment. Motion of the jaw cannot be per- 
mitted in any case where the fracture is far back, since it is then im- 
possible to grasp the posterior fragment between the two parallel splints. 
Nothing but complete immobility of the jaw will now insure immobility 
to the fracture. Some of these forms of apparatus are liable to addi- 
tional objections, which will be readily suggested by an explanation of 
their mode of construction. 

Chopart and Desault originated this idea as early as 1780, for frac- 
tures occurring upon both sides ; in which cases they advised " band- 
ages composed of crotchets of iron or of steel, placed over the teeth, 
upon the alveolar margin, covered with cork or with plates of lead, and 
fastened by thumb-screws to a plate of sheet-iron, or to some other 
material under the jaw." 



110 FRACTURES OF THE LOWER. JAW. 

The apparatus invented by Rutenick, a German surgeon, in 1799, 
and improved by Kluge, is thus described by Dr. Chester: "It con- 
sists, 1st, of small silver grooves, varying in size according as they are 
to be placed on the incisors or molars, and long enough to extend over 
the crowns of four teeth ; 2d, of a small piece of board, adapted to the 
lower surface of the jaw, and in shape resembling a horseshoe, having 
at its tw T o horns, two holes on each side ; 3d, of steel hooks of various 
sizes, each having at one extremity an arch for the reception of the 
lower lip, and another smaller for securing it over the silver channels 
on the teeth, and at the other end a screw to pass through the horse- 
shoe splint, and to be secured to it by a nut and a horizontal branch at 
its lower surface ; 4th, of a cap or silk nightcap to remain on the head ; 
and 5th, of a compress corresponding in shape and size with the splint. 
The net or cap having been placed on the head, and the two straps 
fastened to it on each side, one immediately in front of the ear and the 
other about three inches farther back, which are to retain the splint in 
its position by passing through the two holes in each horn, a silver 
channel is placed on the four teeth nearest to the fracture ; on this the 
small arch of the hook is placed, and the screw end, having been passed 
through a hole in the splint, is screwed firmly to it by the nut, after a 
compress has been placed between the splint and the integuments below 
the jaw. 

" If there is a double fracture, two channels and two hooks must of 
course be used." 1 

Bush invented a similar apparatus in 1822, 2 and Houzelot in 1826 : 
since which the apparatus has been variously modified by Jousset, Lons- 
dale, Malgaigne, and perhaps others. 

Lonsdale says he has employed his instrument in numerous cases, 
and with complete success. 3 Rutenick succeeded with his apparatus 
in a case where the displacement persisted in spite of all other means. 4 
Jousset was also successful in two cases. 5 Wales, Asst. Surg. U. S. 
Navy, suc3eeded with an instrument of his own invention. 6 

But others have not been equally fortunate ; or if they have succeeded 
in holding the fragments in apposition, and in securing a bony union, 
other serious accidents have followed. 

In the first case mentioned by Houzelot, the instrument was kept on 
thirteen days, after which an attack of epilepsy deranged everything, 
and the patient was transferred to Bicebre. The second patient com- 
plained immediately of an intense pain under the chin, and a profuse 
salivation followed. These symptoms were subdued by the sixth day, 
but, for some reason, the apparatus was finally removed on the tenth 
day. The fragments hereafter showed no tendency to derangement. 
Seven days after its removal, an abscess, which had formed under the 
chin, was opened. In the third case the apparatus was left in place 

1 London Med.-Chir. Rev., vol. xx. p. 471, from Monthly Archives of the Medical 
Sciences, 1834. 

2 Malgaigne, op. cit., p. 395. 

3 Lonsdale, Practical Treatise on Fractures ; London, 1838, p. 234. 

4 Malgaigne, op. cit., p. 396. 5 Ibid., p. 396. 
e Wales, Am. Journ. Med. Sci., Oct. 1860. 



FRACTURES OF THE LOWER JAW. 141 

thirty days, and an abscess formed also under the chin. Neucourt ap- 
plied it in a double fracture where the central fragment was much dis- 
placed. The apposition was well preserved, but he was obliged to 
remove it on the seventeenth day on account of a phlegmon which was 
forming under the chin. The patient to whom Bush applied his ap- 
paratus would wear it but a few days. Malgaigne had the same ex- 
perience with Bush's apparatus. 

In addition to the pain and inflammation, followed by submaxillary 
abscesses, which have been such frequent results of its use, Malgaigne 
has noticed that it is exceedingly inclined to slide forwards and become 
displaced. 

In short, notwithstanding the unqualified testimony of Lonsdale in 
favor of this method of treatment, especially in fractures at the sym- 
physis, and in fractures through any portion of the shaft anterior to the 
masseter muscle, it is, in my judgment, applicable to only a very limited 
number of cases ; but if I were to recommend any form of apparatus 
constructed with a view of permitting mobility of the jaws during the 
process of union, it would be that invented by Norman Kingsley, dentist, 
of this city, and which I have seen used with excellent results at Bellevue 
Hospital. 

Impressions in plaster are first taken of both upper and lower jaws. 
Models made from these impressions will represent the lower jaw broken 
and the fragments displaced. The 
model of the lower jaw is then 
separated at the point represent- 
ing the fracture, and the frag- 
ments adjusted to the model of 
the upper jaw. In most cases the 
position which these fragments 
assume when thus placed deter- 
mines accurately the original form 
and position of the lower jaw. 
Upon the plaster model of the 
lower jaw, obtained and rectified 
in this way, a splint or clasp of 
vulcanite rubber is then made, embracing the arms, which are made of 
steel wire, one-sixteenth of an inch in diameter. The arms must curve 
upwards a little as they emerge from the mouth, to avoid pressure upon 
the lips, and then curve backwards, terminating near the angles of the jaw. 

When the apparatus is applied, the teeth must be pushed into the 
sockets of the splint with some force. The dressing is now completed 
by a sling made of strong muslin, extending beneath the chin from one 
arm to the other. 

Dr. Kingsley says, in his late excellent work on "Oral Deformities," 
that he was not aware of the fact until recently that Mr. Hay ward, of 
London, had so early as 1858 constructed a similar, but, as I think, less 
perfect apparatus. 1 



w ,:i i*! 




Plaster model of jaws. 



1 "Oral Deformities," by Norman W. Kingsley, M.D.S., D.D.S., New York, pp. 

397-399. Appleton, 1880. 



142 



FRACTURES OF THE LOWER JAW 



George L. Fitch, dentist, California, believes that "dental gutta 
percha" may be made to answer the same purpose as vulcanite rubber. 



Fig. 30. 




Kingsley's apparatus applied to model. (From Kingsley.) 

in the construction of this and other similar splints. 1 In this opinion, 
however, Dr. Kingsley does not concur. 



Fig. 31. 



Fig. 32. 





Kingsley's apparatus applied to patient. (From 
Kingsley.) 




Gibson's bandage for a fractured }aw. 



The treatment of fractures of the inferior maxilla by a single-headed 
bandage or roller, numbers among its distinguished advocates the names 



Fitch, New York Med. Gazette, 1869. 



FRACTURES OF THE LOWER JAW 



14; 



of Gibson and Barton ; indeed, I think the practice is at the present 
time peculiar to a few American surgeons. Gibson gives the following 
directions for applying his roller: "A cotton or linen compress, of 
moderate thickness, reaching from the angle of the jaw nearly to the 
chin, is placed beneath, and held by an assistant, while the surgeon 
takes a roller, four or five yards long, an inch and a half wide, and 
passes it by several successive turns under the jaw, up along the sides 
of the face, and over the head ; now changing the course of the bandage, 
he causes it to pass off at a right angle from the perpendicular cast, and 
to encircle the temple, occiput, and forehead, horizontally, by several 
turns ; finally, to render the whole more secure, several additional hori- 
zontal turns are made around the back of the neck, under the ear, along 
the base of the jaw, under the point of the chin. To prevent the roller 
from slipping or changing its position, a short piece may be secured by 
a pin to the horizontal turn that encircles the forehead, and passed 
backwards along the centre of the head as far as the neck, where it must 
be tacked to the lower horizontal turn — taking care to fix one or more 
pins at every point at which the roller has crossed." 

Barton employed, also, a compress, and a roller five yards long ; the 
application of which is thus described by Sargent : Place the initial 
extremity of the roller upon the occiput, just below its protuberance, 
and conduct the cylinder obliquely over the centre of the left parietal 
bone to the top of the head ; thence descend across the right temple and 
the zygomatic arch, and pass beneath the chin to the left side of the 
face ; mount over the left zygoma and temple to the summit of the 
cranium, and regain the starting-point at the 
occiput by traversing obliquely the right pari- 
etal bone ; next wind around the base of the 
lower jaw on the left side to the chin, and 
thence return to the occiput along the right 
side of the maxilla ; repeat the same course, 
step by step, until the roller is spent, and 
then confine its terminal end. 

These bandages possess the advantages of 
being easily obtained, of simplicity and facility 
of application, and, we may add, if considered 
in relation to the majority of simple fractures, 
of tolerable adaptation to the ends proposed. 
The only objections to their use which I have 
ever noticed, are occasional disarrangements, 
and the tendency, as in all other continuous 
rollers, to draw the fragments to one side or the other, according as the 
successive turns of the bandage are carried to the right or left. There 
is one other objection, having reference to the occasional inadequacy of 
this dressing to prevent an overlapping of the fragments ; to which ob- 
jection also the sling, as usually constructed, is equally obnoxious, and 
of which I shall speak presently. 

Finally, it is to the sling, in some of its various forms, with or without 
the interdental splint, that surgeons have generally given the preference. 



Fig. 33. 




Barton's bandage for i 
fractured jaw. 



144 



FRACTURES OF THE LOWER JAW. 



Fig. 34. 



The sling is known, also, by the 



name 




Four-tailed bandage or sling for the 
lower jaw. 



of the four-headed or the four-tailed 
roller or bandage. 

B. Bell, Boyer, Skey, S. Cooper, 
B. Cooper, Syme, Fergusson, Mayor, 
Lizars, and Chelius employ the sling, 
usually ; and the favorite mode is to 
use for this purpose a piece of muslin 
cloth about one yard long and four 
inches wide, torn down from its ex- 
tremities to within about three or four 
inches of the centre. Others have 
used leather, gutta percha, adhesive 
straps, gum-elastic, etc. 

Where the muslin is used, it is quite 
customary to lay against the skin 
a piece of pasteboard, wetted and 
moulded to the chin, or simply a soft 
compress ; and some choose to open 
the centre of the bandage sufficiently 
to receive the chin. The middle of this bandage being laid upon the 
chin, the two ends corresponding to the upper margin of the roller are 
now carried across the front of the chin, behind the nape of the neck, 
and made fast ; while the two lower heads are brought directly upwards 
from under the sides of the chin, along the sides of the face, in front of 
the ears, and made fast upon the top of the head. The dressing is com- 
pleted by a short counter-band extending across the top of the head from 
one bandage to the other ; or the several bands may be made fast to a 
nightcap, in which case the counter-band will be unnecessary. 

It only remains for me to describe my own method of dressing these 
fractures with the sling. 

Having frequently noticed the tendency of the sling, as ordinarily 
constructed, and of Gibson's roller, to carry the anterior fragment back- 
wards, especially in double fracture where the body of the bone is 
broken upon both sides, I devised, some years since, an apparatus in- 
tended to obviate this objection, and which I have used now many times 
with entire satisfaction. 

It is composed of a firm leather strap, called maxillary, which, pass- 
ing perpendicularly upwards from under the chin, is made to buckle 
upon the top of the head, at a point near the situation of the anterior 
fontanelle. This strap is supported by two counter-straps, made of 
strong linen webbing, called, respectively, the occipitofrontal and the 
vertical. The occipitofrontal is looped upon the maxillary at a point 
a little above the ears, and may be elevated or depressed at pleasure. 
The occipital portion of the strap is then carried backwards and buckled 
under the occiput, while the frontal portion is buckled across the fore- 
head. The vertical strap unites the occiptal to the maxillary across the 
top of the head, and prevents the upper part of the latter from becom- 
ing displaced forwards. At each point where a buckle is used, a pad 
must be placed between the strap and the head. 



FRACTURES OF THE LOWER JAW. 



145 



Fig. 35. 



The maxillary strap is narrow under the chin, to avoid pressure upon 
the front of the neck, but immediately becomes wider, so as to cover 
the sides of the inferior maxilla and face, after which it gradually dimin- 
ishes, to accommodate the buckle upon the top of the head. The ante- 
rior margin of this band, at the point corresponding to the symphysis 
menti, and for about two inches on each side, is supplied with thread- 
holes, for the purpose of attaching a piece of linen, which, when the 
apparatus is in place, shall cross in front of the chin, and prevent the 
maxillary strap from sliding backwards against the front of the neck. 

The advantage of this dressing over any which I have yet seen, con- 
sists in its capability to lift the anterior fragment almost vertically, 
while at the same time it is in no danger of falling forwards, and down- 
wards upon the forehead. If, as in the case of most other dressings, 
the occipital stay had its attachment opposite to the chin, its effect would 
be to draw the central fragment backwards. By using a firm piece of 
leather, as a maxillary band, and attaching the occipital stay above the 
ears, this difficulty is completely obviated. 

Having removed such teeth as are much loosened at the point of frac- 
ture, and replaced those which are loosened at other points, unless it be 
far back in the mouth, and adjusted the fragments accurately, the lower 
jaw is to be closed completely upon 
the upper, and the apparatus snugly 
applied. It is not necessary in most 
cases to buckle the straps Avith great 
firmness, since experience has shown 
that a sufficient degree of immobility 
is usually obtained when the apparatus 
is only moderately tight. 

If the integuments are bruised and 
tender, a compress made of two or 
more thicknesses of patent lint should 
be placed underneath the chin, be- 
tween it and the leather. 

If the inability to introduce nourish- 
ment between the teeth when the 
mouth is closed, or the irregularity of 
the dental arcade renders the use of 
interdental splints necessary, gutta 
percha, as I have already explained, 
ought, in general, to be preferred to 
any other material. 

_ The patient must be forbidden to talk or laugh, and when he lies down, 
his head should rest upon its back, for whatever mode of dressing is 
employed, and however carefully it is applied, it will be found that a 
slight motion and displacement will occur whenever the weight of the 
head rests upon the side of the face. 

Occasionally, indeed, as often as every two or three days, the appa- 
ratus may be loosened or removed, only taking care generally not to 
disturb the interdental splints, when they are used, and to support the 
jaw with the hand, during its removal; and, at the same time, the face 




The author's apparatus. 



146 FRACTURES OF THE LOWER JAW. 

may be sponged off with warm water and castile soap. It should not be 
left off entirely, however, in less than three or four weeks, even where 
the fracture is most simple, nor ought the patient be allowed to eat meat 
in less than four or five weeks. 

To cleanse the mouth and prevent offensive accumulations, it should be 
washed several times a day with a solution of tincture of myrrh, prepared 
by adding one drachm to about four ounces of water. 

The same apparatus, and without any essential modification, is appli- 
cable to fractures of the symphysis and of the angle of the inferior max- 
illa, as well as to fractures of the body of the bone. 

Instead of the leather, I have in a few instances, especially of com- 
pound fractures where it became necessary to allow the pus to discharge 
externally, used a sling or a splint composed of gutta percha, suspended 
by bands carried over the top of the head. The piece from which this 
splint is made should be three or four lines in thickness, covered with 
cloth, and padded under the chin. It will be found convenient to cover 
it with cloth before immersing it in the hot water. The water should be 
nearly at a boiling temperature, so that the splint may become perfectly 
pliable ; and it should be laid upon the face and allowed to mould itself 
while the patient lies upon his back. 

Having thus fitted it accurately to the face, it may be removed and 
openings made at points corresponding with the wounds upon the skin, 
before it is reapplied. 

As has been already explained, the gutta percha, if sufficiently thick, 
and if the lateral wings are allowed to project a little on either side, 
will serve effectually to protect the sides of the face against pressure 
from the bandage ; and being more easily moulded to the base and front 
of the chin than any other material which has yet been employed, must 
have the preference. The necessity for its use, however, is only occa- 
sional. 

Dr. S. 0. Vanderpool, Jr., late House Surgeon at Bellevue, has em- 
ployed successfully a modification of my apparatus, made of plaster-of- 
Paris bandage. 1 The apparatus having been applied over a linen night 
cap, and having been permitted to harden, the maxillary straps are cut 
on a line with the ears, or portions removed and pieces of webbing with 
buckles substituted. The pieces of webbing may be fastened with stitches 
or Avith plaster. Perhaps it would be quite as well to leave the bandage 
as at first applied until a change becomes necessary — possibly a week 
or two — and then cut and insert the webbing. 

In fractures of either condyle, unaccompanied with displacement, the 
simple leather or muslin sling will sometimes accomplish a perfect and 
speedy cure, as the two cases reported by Desault will sufficiently demon- 
strate. But if the fragments have become separated, the replacement is 
difficult, and the retention uncertain. 

Ribes was the first to suggest and to practise a very ingenious method 
of reduction in these cases. Having seen two examples which had re- 
sulted in deformity under the usual treatment, which consisted in simply 
pressing forwards the angle of the jaw, it occurred to him that while the 

1 Vanderpool, Archives of Clinical Surgery, Jan. 1, 1878. 



FRACTURES OF THE HYOID BONE. 147 

upper or condyloidean fragment was not acted upon at the same moment 
by pressure from the opposite direction, a reduction must be impossible. 
The case of a cannoneer whose jaw was broken through the neck of the 
condyle on the right side, and through its body on the left, afforded him 
an opportunity to determine the practicability of a method of which he 
had as yet only conceived the idea. Malgaigne thus describes his pro- 
cedure: "With the left hand seize the anterior portion of the jaw, for 
the purpose of drawing it horizontally forwards, while you carry the 
index finger of the right hand to the lateral and superior part of the 
pharynx. You will meet at first the projection formed by the styloid 
process, but, moving your finger forwards, you will find soon the poste- 
rior border of the ramus of the jaw; and following this border from 
below upwards, you will arrive at the inner side of the condyle, w T hich 
you will push outwards in such a manner as to engage it upon the other 
fragment. This manoeuvre cannot be made without causing nausea, as 
the finger always does when carried into the posterior part of the pha- 
rynx; but this is a slight inconvenience. The reduction obtained, bear 
the jaw upwards and backwards in order to press and fix the condyle 
between it and the glenoid cavity, then fasten it in place with a sling." 
The fragments were thus easily brought into apposition in the case re- 
ported by Ribes, and the patient was cured without any deformity. 

In addition to these means, the angle of the jaw ought to be pressed 
permanently forwards by means of a compress placed between it and 
the mastoid process, and held in place by a suitable bandage ; or we 
may adopt the method which proved so successful with Fountain, namely, 
wire the front teeth of the lower jaw to the front teeth of the upper in 
such a manner as to draw the chin forwards, and thus maintain apposition. 

If the coronoid process be alone broken, it is sufficient to close the 
mouth with any form of sling or bandage which may be most convenient. 

In cases of delayed or non-union of the fragments, we may resort to 
the wire ligature, as was practised by myself in certain cases already 
described, or to any other of those expedients described in the chapter 
on General Prognosis. In Dr. Muhlenberg's tables, 14 cases are re- 
corded. Of seven treated by mechanical appliances, 5 were cured, 1 
was relieved, and 1 died : and of 7 treated by drilling, with its modifi- 
cation, all were reported cured. 



CHAPTEE XIV. 

FRACTURES OF THE HYOID BONE. 

M. Orfila has reported the case of a man, aged sixty-two years, who 
had been hanged, and whose os hyoides was broken through its body on 
its right side. 1 M. Cazauvieilh has also seen a fracture of this bone in 

1 Traite de Med. legale, troisieme ed., torn. ii. p. 423. 



148 FRACTURES OF THE HYOID BONE. 

two persons who had been hanged : in one of which the fracture was 
probably in the body of the bone, and in the other through one of its 
cornua. 1 

Lalesque published in the Journal Hebdomadaire for March, 1833, a 
case w T hich occurred in a marine, sixty-seven years old, " who, in a 
quarrel, had his throat violently clenched by the hand of a vigorous 
adversary. At the moment there was very acute pain, and the sensation 
of a solid body breaking. The pain was aggravated by every effort to 
speak, to swallow, or to move the tongue, and when this organ was pushed 
backwards, deglutition was impossible. The patient could not articulate 
distinctly; and he was unable to open his mouth without exciting a great 
deal of pain. He placed his hand upon the anterior and superior part 
of his neck to point out the seat of the injury. This part was slightly 
swollen, and presented on each side small ecchymoses ; one above, more 
decided, immediately under the left angle of the lower jaw. The large 
cornu of the os hyoides was very distinctly to the right side," and it 
could be felt on the left deeply seated by pressing with the fingers ; in 
following it in front toward the body of the bone, a very sensible in- 
equality near the point of junction of these two parts could be perceived. 
By putting the finger within the mouth, the same projections and cavi- 
ties inverted could be felt, and even the points of the bone which had 
pierced the mucous membrane, etc., were evident. Having bled the 
patient, and placed a plug between his teeth to keep the mouth open, the 
broken branch was brought by the finger back to the surface of the body 
of the bone, and easily reduced. The position of the head inclined a 
little back ; rest, absolute silence, diet, and some saturnine fomentations, 
composed the after-treatment. To avoid a new dislocation by the efforts 
of swallowing, the oesophagus-tube of Desault was introduced, to con- 
duct the drinks and liquid aliments into the stomach ; this sound was 
allowed to remain until the twenty-fifth day ; at this time the patient 
could swallow without pain, and began to take a little more solid nour- 
ishment, and at the end of two months the cure was complete. By 
placing a finger within his mouth, a slight nodosity could be felt in the 
place where, in the recent fracture, the splintered points were percepti- 
ble. 2 

Dieffenbach has also recorded a fracture of the great right horn, pro- 
duced in the same manner, by grasping the throat between the thumb 
and fingers, which occurred in a girl only nineteen years old. Very 
slight pressure upon the side of the bone was sufficient to move the frag- 
ment inwards, and to produce a crepitus ; but it immediately resumed 
its place when the pressure was removed. There being, therefore, no 
displacement, the cure was effected in a short time without resort to any 
remedies except tisans and antiphlogistics. She was not even forbidden 
to speak. 3 

Auberge saw a similar case, in a person fifty-five years old, occasioned 
by grasping the throat. The fracture was in the great horn of the right 

1 Cazauvieilh, du Suicide, etc., p. 221. 

2 Amer. Journ. Med. Sci., vol. xiii. p. 250. 

3 Medic. Vereinszeitung fur Preussen, 1833, No. 3 ; Gazette Med., 1834, p. 187. 



FRACTURES OF THE HYOID BONE. 149 

side, and the displacement was so complete that crepitus could not be 
felt, and the mucous membrane of the pharynx was penetrated by the 
broken bone. 1 

The following example is reported by Dr. Wood, of Cincinnati, Ohio, 
as having come under his observation in the year 1855 : — 

" Through the kindness of our friend Dr. P. G. Fore of this city, we 
were invited to examine a case of fracture of the os hyoides, that had 
occurred about one week before we saw it, in one of his patients. The 
patient was a female, about thirty years of age, w T ho had fallen down 
the cellar steps, striking the prominent parts of the larynx and hyoid 
bone against a projecting brick, severely injuring the larynx as well as 
fracturing the bone. 

" The fracture was on the left side, and near the junction of the great 
horn with the body of the bone. Crepitus was distinctly felt on pressing 
the bone between the thumb and finger ; or when the patient would swal- 
low; though, at this time, the severe symptoms that followed the acci- 
dent, and continued for several days, had somewhat subsided. 

" Immediately after the accident there was profuse bleeding from the 
fauces, and she experienced great difficulty and pain in the act of swal- 
lowing, and the power of speech was almost entirely lost. On attempt- 
ing to depress or protrude the tongue, she felt distressing symptoms of 
suffocation. Considerable inflammation and swelling of the throat and 
larynx ensued, and continued in same degree up to the time of o.ur visit. 

" To-day (about four weeks since the accident) Dr. F. informs us that 
the patient has so far recovered as to be able to converse, though the 
voice is somewhat impaired. She is yet unable to swallow solid food, 
and is wholly sustained by fluids.'' 2 

Marcinkovsky saw a woman in whom both the lower jaw and the left 
horn of the os hyoides were broken by a fall from her carriage against 
a wall. She died in about twenty-four hours, from suffocation. 3 

Dr. Griinder reports the following: — 

"A laborer, 89 1. 63, fell from a wagon on his face, and discharged a 
large quantity of blood by the mouth. He found he could not swallow, 
and when seen twelve hours afterward, complained of severe pain in the 
neck and nape, with inability to turn his head, though no injury of the 
vertebrae could be detected. His voice was hoarse and difficult. On 
attempting to drink, the fluid was rejected with violent coughing, the 
patient declaring he felt it as if entering the air-passages. An examina- 
tion of the fauces led to no explanation of this condition. The epiglottis 
did not, however, appear to completely close the larynx, or to be in its 
exact position. The tongue was movable in all directions, and pressing 
it down with a spatula caused no inconvenience. The hyoid seemed to 
possess its continuity. No crepitation or abnormal movability could be 
perceived, and no pain at the root of the tongue occurred on attempting 
to swallow. After repeated examinations, the case was concluded to be 
one in which the functions of the nervus vagus had undergone great dis- 

1 Revue Med., July, 1S35. 

2 Western Lancet ; also N. Y. Journ. Med., vol. xv. p. 152. 

3 Medic. Vereinszeitung fur Preussen, 1833, No. 15 ; Gazette Medicale, 1833, p. 354. 



150 FKACTURES OF THE HYOID BONE. 

turbance, or the muscles of the larynx had become torn or paralyzed. 
Medicine and food were administered by means of an elastic tube. The 
patient had a good appetite and slept well; the pain of the neck was 
lost, and its motion recovered; a hectic cough, from which he had long 
suffered, alone remaining. After continuing, however, to go on thus 
well for six days, the cough increased ; the appetite failed ; strength was 
lost ; the voice was scarcely audible ; and in five more days the patient 
died exhausted. At the autopsy a fracture of the os hyoides was found. 
One of the large cornua was broken, and had become firmly imbedded 
between the epiglottis and rima glottidis, inducing the raised position of 
the epiglottis, loss of voice, and difficulty in swallowing. The fracture 
was probably produced by muscular action, a cause first assigned in a 
case occurring to Ollivier d' Angers." 1 

I think it more probable that this fracture was the result of a direct 
blow, than of muscular action. In the case referred to, however, as 
having been reported by Ollivier, there can be no doubt that the fracture 
was due to muscular action alone. 

A woman, fifty-six years old, made a misstep and fell backwards, and 
at the same moment that her head was thrown violently back, she felt 
distinctly a sensation as if a solid body had broken, in the upper part of 
her neck and upon its left side. An examination showed that she had 
fractured the great left horn of the os hyoides. Inflammation and sup- 
puration followed, and finally, after about three months, the posterior 
fragment made its way out in a condition of necrosis, and the fistula 
promptly healed, but there remained for many years a sense of uneasi- 
ness about these parts when she swallowed, sometimes amounting to pain. 2 

Etiology. — Of the ten cases which I have found upon record, three 
were produced by hanging; three by grasping the throat between the 
thumb and fingers ; three by direct blows, or by falls upon the front of 
the neck; and one by muscular action alone. 

The observation of Mr. South, that fracture of the bone " is almost 
invariably found" 3 in persons executed by hanging, is probably incor- 
rect, since although a large proportion of these subjects are submitted 
to dissection both in this and other countries, yet I know of but these 
three examples which have been published. 

Pathology, Symptomatology , and Diagnosis. — The body of the bone 
seems to have been broken in all of those cases which resulted from 
hanging ; while in all of the other examples the fracture has occurred 
in one of the great horns, or at the junction of the horns with the body. 
Generally the displacement inwards of one of the fragments has been so 
complete that crepitus could not be detected. It was present, however, 
in the examples mentioned by Dieftenbach and Wood. In two instances 
the mucous membrane has been penetrated, and in one the fragment was 
projected between the epiglottis and rima glottidis. 

The accident has been characterized by a sudden sensation as if a 



1 Schmidt's Jahrbuch., vol. lxviii.; also Amer. Journ. Med. Sci., vol. xlix. p. 253, 
Jan. 1S52. 

2 Malgaigne, op. cit., p. 405. 

;s Note to Chelius's Surgery, Amer. ed., vol. i. p. 581. 



FRACTURES OF THE HYOID BONE. 151 

bone had broken; in a few instances, by profuse bleeding from the 
fauces ; by difficulty in opening the mouth ; by impossibility of deglu- 
tition, and by loss of voice in others ; with great pain in moving the 
tongue, the pain being especially at its root; in one instance the tongue 
was perceptibly drawn to one side. There is usually more or less swell- 
ing and soreness about the neck, with ecchymosis ; and at a later period, 
cough, expectoration, hoarseness, etc. The circumstances which, how T - 
ever, indicate certainly the nature of the accident, are preternatural 
mobility of the fragments, with or without crepitus, and the angular in- 
ward projection, which may in most cases be distinctly felt in a careful 
examination of the pharynx. 

In the case related by Griinder, the only symptoms were a loss of 
voice, difficulty of deglutition, and a sensation, when the attempt was 
made to swallow, as if the fluids passed into the windpipe; with also an 
imperfect closure of the epiglottis upon the rima glottidis. No preter- 
natural mobility or irregularity in the fragments could be detected, nor 
was there crepitus, and it was concluded that the bone was not broken, 
yet the autopsy showed that the fragment was imbedded deeply between 
the epiglottis and the rima glottidis. 

Prognosis. — It is only in view of its complications that this accident 
can be regarded as serious; where the severity of the injury has been 
such as to fracture the lower jaw at the same time, as in the case related 
by Marcinkovsky, or such as to bury the fragment deep in the tissues 
about the rima glottidis, as in the case mentioned by Grunder, a favor- 
able termination could scarcely have been expected ; and these are the 
only cases yet published in which the death was in any way connected 
with the fracture. One-half of the whole number have died, but of these, 
three have died by hanging, and the remaining two from the causes 
named. Of the three in which the accident resulted from a direct blow, 
only the patient of Dr. Fore, of Cincinnati, has survived; while of the 
three whose fractures resulted from lateral pressure upon the cornua all 
recovered; so, also, did the patient in whom the fracture was produced 
by muscular action. 

Treatment. — No doubt when the fragments are displaced an attempt 
ought to be made to replace them by introducing one finger into the 
mouth, while w r ith the opposite hand the fragments are supported from 
without. Lalesque found this a matter of some difficulty, but Auberge 
experienced no difficulty at all. I suspect, however, that the amount 
of difficulty will very much depend upon the degree of displacement, 
and the consequent lacerations of the soft tissues about the bone. But 
however this may be, it must be altogether another thing to be able to 
keep in exact apposition the broken ends of a bone whose diameter is 
so inconsiderable, and upon which it is quite impossible to apply any 
apparatus or dressings to retain the fragments in place. Lalesque threw 
the head of his patient slightly back, with the view of making " perma- 
nent extension" upon the fragments through the action of the muscles 
and ligaments attached to the bone, and he recommends this position as 
that which is best calculated to preserve the coaptation. Malgaigne, on 
the contrary, without having himself seen any example of this fracture, 



152 FRACTURE OF THE CARTILAGES OF THE LARYNX. 

believes that the position of flexion of the neck, with entire relaxation 
of the muscles, would be most suitable. 

In all cases it will be proper to enjoin silence, and to adopt suitable 
measures to combat inflammation ; such as general or topical bleeding, 
fomentations, moistening the mouth with cool, water, or permitting small 
pieces of ice to rest in the mouth until dissolved, without in general al- 
lowing the fluid to be swallowed ; but in some examples, no doubt, the 
patient may be permitted to swallow. 



CHAPTEE XV. 

FRACTURE OF THE CARTILAGES OF THE LARYNX. 

§ 1. Thyroid Cartilage. 

The examples of fracture of the larynx which may be found upon 
record are also very few. M. Ladoz examined the larynx of a man who 
had been assassinated, and upon whose neck he found a handkerchief 
bound so tightly as to leave, after its removal, a deep furrow ; but the 
neck showed also distinct marks produced by the fingers and thumb. 
There was a fracture of the thyroid cartilage w T hich extended obliquely 
downwards, and outwards through its right wing. The whole of the 
larynx was very ■much ossified, although the subject was only thirty- 
seven years old. 1 

In 1823, M. Ollivier communicated to the Academy of Medicine a 
case in which, this cartilage being broken, the patient died of suffocation. 2 

M. Marjolin says : " Two women at the hospital being engaged in a 
quarrel, one of them seized her antagonist by the throat, and griped her 
so strongly that she broke the thyroid cartilage from its upper to its 
loAver margin. You will imagine that it was not very difficult to deter- 
mine the existence of fracture, and that no retentive apparatus was de- 
manded. Silence, regimen, a small bleeding, and the cure was accom- 
plished." 3 

Habicot operated successfully, in 1620, by introducing a leaden tube 
into the trachea in a case in which the thyroid was " damaged." Gibb, 
Norris, Nelaton, and Kenderline have each reported examples of fracture 
of this cartilage alone. 4 

§ 2. Thyroid and Cricoid Cartilages. 

Plenck saw a fracture of both the thyroid and cricoid cartilages pro- 
duced by falling upon the rim of a pail. 5 Morgagni also says that he 

1 Gazette Medicale, 1838, p. 698. 

2 Archives Generales de Medecine, tome ii. p. 307. 

3 Marjolin, Cours de Patholog. Chir., p. 396. 

4 Hunt, Frac. of Larynx, etc. Am. Journ. Med. Sci., April, 1866. 

5 Malgaigne, op. cit., p. 409. 



THYROID AND CRICOID CARTILAGES. 153 

had seen fractures of the larynx ; and Remer mentions a fracture of the 
larynx found in a person who had been hanged j 1 but in neither case is 
it said in which cartilage the fracture occurred, or whether it had not 
occurred in both. 

Dr. O'Brian, of Edinburgh, reports in vol. xviii. of the Edinburgh 
Med. and Surg. Joum., a case of fracture of both cartilages, involving 
the trachea also, in a woman who had received a kick under the jaw, 
and who died on the following day. Hunt has collected other cases, 
some of which involved the arytenoid cartilages, the hyoid bone, the 
trachea, etc. 

I am able to furnish, from my own observation, another example of 
fracture of both the thyroid and cricoid cartilages. 

John Calkins, of Collins, Erie Co., N. Y., set. 41, is supposed to have 
been kicked by a young horse on the 10th of November, 1856. He was 
alone in the stable when the accident occurred, and, being stunned by 
the blow, he could not himself give any account of the manner in which 
the injury was received. When found, he was sitting upright, but un- 
able to articulate except in a whisper. Drs. Barber and Davis, of Colden, 
saw him about two hours after. His countenance was anxious ; his pulse 
feeble ; extremities cold ; and he was breathing with great difficulty. 
A small quantity of blood was issuing from his fauces. His upper lip 
was cut, and a few of his teeth dislocated ; the wound appearing as if 
inflicted by one of the corks of the horse's shoes. There was no other 
wound ; but over the left wing of the thyroid cartilage there was a 
slight discoloration, pressure upon which produced intense pain and suf- 
focation, and disclosed the fact that the thyroid prominence was depressed 
very much and broken. Cold lotions were directed to be applied, and as 
the thirst was excessive, but deglutition impossible, he was permitted to 
hold pieces of ice in his mouth. This plan, with but slight modifica- 
tions, such as the substitution of warm fomentations to the neck for the 
cold lotions, was continued until the following evening, when, at the re- 
quest of the attending physician, Dr. Barber, I was called to see him. 
The symptoms remained nearly the same as at first. He was unable to 
speak audibly, or perform the act of deglutition ; his breathing was diffi- 
cult, and at times threatened suffocation. The lateness of the hour, with 
other circumstances, determined me to defer surgical interference until 
morning. At daybreak of the 12th I made the operation of laryngot- 
omy, and introduced a large double canula into the crico-thyroidean 
space. This operation was rendered difficult by the great amount of 
swelling about the neck, due both to emphysema, and bloody with serous 
infiltrations. The breathing immediately became easy, and gradually 
the appearance of asphyxia disappeared from his face ; but after about 
six or seven hours he began perceptibly to fail in strength, and died at 
3 o'clock P. M. of the following day, apparently from exhaustion rather 
than from suffocation ; having survived the accident about seventy-two 
hours, and the operation about thirty-four hours. 

The autopsy disclosed a comminuted fracture of the thyroid cartilage, 



1 Morgagni, de Sedibus, etc., Epist. 19, num. 13, 14, et 16 ; Remer, Annales d'Hj- 
giene, tome iv. p. 171 ; from Malgaigne. 
11 



154 FRACTURE OF THE CARTILAGES OF THE LARYNX. 

with a simple fracture of the cricoid. The thyroid was broken almost 
perpendicularly through the centre ; the line of fracture being irregular, 
and inclining slightly to the left side. The left inferior horn was broken 
off abomt three lines from its articulation with the cricoid cartilage. The 
right ala was broken also in a line nearly vertical, but irregular, at a 
point about six lines from its posterior margin. The pomum Adami 
was depressed to the level of the cricoid cartilage, and the left ala, being 
completely detached, was thrown inwards and upwards several lines. 
Underneath the perichondrium, especially upon the inner side, there 
was pretty extensive bloody infiltration. Ossification of the cartilages 
had commenced at several points, but it had made but little progress. 
The central fracture of the thyroid was through cartilage alone. The 
fracture of the right ala was through cartilage until it reached a bony 
belt comprising the two inferior lines of its course. The left lower horn 
was ossified, and the fracture was through this bony structure. The 
fracture through the cricoid cartilage commenced close upon the margin 
of a bony plate, but in its whole course it traversed only cartilage. It 
was on the left side. There was also an incomplete fracture on the 
right ala of the thyroid cartilage, commencing in the line of the principal 
fracture and extending obliquely downwards about three lines, until it 
was arrested by the bony plate which constituted the lower margin of 
this wing. 

A ragged, lacerated wound in the back of the larynx, above the cricoid 
cartilages, communicated directly with the oesophagus. 

§ 3. Cricoid Cartilage. 

Both Valsalva and Cazauvieilh have each met with a single example 
of this fracture, without fracture of the thyroid cartilage ; and Weiss 
has found the cricoid cartilage broken into numerous fragments, and at 
the same time separated from the trachea. 1 

General Etiology of Fractures of the Laryngeal Cartilages. 
As a predisposing cause, advanced age, with its usual concomitant, partial 
or complete ossification of the cartilages, has been thought to occupy a 
prominent place. In the case reported by Plenck, the cartilages were 
already very much ossified, although the subject was only thirty-seven 
years old. Morgagni observed that in his experience it had occurred 
always in advanced life. In my own case, however, the cartilages were 
only slightly ossified, the patient being forty-one years old ; nor did 
the lines of the several fractures indicate a preference for the bony 
plates ; but it seems to me that they rather avoided them, and in the 
case of the incomplete fracture the bone appeared to have arrested the 
fracture. In fact, a few experiments have satisfied me that the adult 
laryngeal cartilages are quite as brittle as bone, and, consequently, that 
ossification in no way increases their liability to fracture. 

Hunt ascertained the age in fifteen cases, and but one of the whole 

1 Malgaigne, op. cit., p. 408. 



CRICOID CARTILAGE. 155 

number was over 45 years ; five occurred in children, one of whom was 
only four years old. 

The immediate causes have been direct blows, as falling upon the edge 
of a pail, a kick from a horse, or pressure, as in hanging, or in grasping 
the larynx strongly between the thumb and fingers. 

General Symptomatology, Etc. — .The signs of this accident are such 
as may attend any severe injury of this organ, whether accompanied 
with a fracture or not, such as pain, swelling, difficult deglutition, em- 
barrassed respiration, loss of voice, cough, and perhaps bloody expecto- 
ration, with emphysema, etc. 

But none of those can be regarded as diagnostic ; although, when 
taken in connection with the history of the accident, especially if a very 
severe and direct blow has been received, or more certainly still when 
symptoms so grave and complicated have followed an attempt at strangu- 
lation by grasping the throat, they may be regarded as probable or pre- 
sumptive evidences. 

A positive diagnosis must depend upon the presence of a sensible 
displacement, or motion of the fragments, with crepitus. 

In the case related by Plenck, death followed almost immediately, 
with convulsions, and without any outcry ; indicating, probably, some 
severe lesion of the spinal marrow ; while in M. Ollivier's patient suffo- 
cation ensued, at first intermittent, and finally permanent. 

In my own case, suffocation was throughout a prominent symptom, 
with only such slight intervals of amelioration as might have been oc- 
casioned by the extrication of the blood or mucus from the larynx. 

General Prognosis. — The prognosis ought to depend rather upon 
the complications and upon the gravity of the symptoms, than upon the 
simple decision of the question of fracture. A fracture produced by 
grasping the wings of the thyroid cartilage, and without any great con- 
tusion or laceration of the soft parts, might reasonably be expected to 
terminate favorably under judicious management ; but when, on the con- 
trary, the fracture is the result of great violence inflicted directly upon 
the front of the cartilages, producing severe contusion and laceration, 
and is followed by great swelling, emphysema, very difficult respiration, 
complete aphonia, impossibility of deglutition, etc., the prognosis can- 
not but be unfavorable. 

General Treatment. — In examples of simple, uncomplicated fracture, 
"silence, regimen, and a small bleeding" may suffice ; but in other 
cases it may become necessary to introduce a tube into the stomach, to 
supply the patient with food and drink, since deglutition may be impos- 
sible. If, also, suffocation is imminent, there may remain no alternative 
but a resort to tracheotomy or to laryngotomy. 

Indeed, one of these operations ought, we think, to be resorted to in 
all cases in which emphysema is prominent. Dr. William Hunt, of the 
Pennsylvania Hospital, in his excellent paper on " Fractures of the 
Larynx and Ruptures of the Trachea," in which he has arranged a tabu- 
lar synopsis of twenty-nine cases, says that of seventy-seven cases ten 



156 FRACTURES OF THE VERTEBRAE. 

recovered and seventeen died. Of eight cases in which tracheotomy 
was performed, but two died. In the four cases in which recovery took 
place without an operation, no mention is made of bloody expectoration 
or of emphysema. 1 

As to a "reduction" of the fragments by manipulation, I believe it 
will be found generally, if not always, impracticable. Whatever dis- 
placement exists must be mostly inwards, and we can have no means of 
forcing them again outwards. Nor, if once replaced, do I see any rea- 
son to suppose that they would not become immediately displaced. 

Chelius has suggested the propriety, in such cases, of cutting open 
the coverings of the larynx freely in the median line, and, after stanch- 
ing the bleeding, proceeding at once to divide the larynx itself in its 
whole length, and then replacing the broken cartilages. 2 The procedure 
has an aspect of severity, but I can well conceive of circumstances which 
would justify its adoption ; not, however, so much for the purpose of 
replacing the cartilages, as for the purpose of arresting a fatal internal 
hemorrhage, and of giving a free admission of air to the lungs. If this 
operation were to be practised, the wound ought to be left open for a 
sufficient length of time to allow of the subsidence of the inflammation, 
and then permitted to close with such precautions as experience teaches 
are usually necessary after the windpipe has been opened. 

Active antiphlogistic measures, combined with fomentations to the 
neck, so far as these latter are found to be agreeable and practicable, 
are important measures, and not to be overlooked in the general plan of 
treatment. 

My own patient, also, found small pieces of ice, permitted slowly to 
dissolve in the mouth, very grateful ; but he preferred very much, as an 
external application, the warm fomentations to the cold lotions. 



CHAPTER XYI. 

FRACTURES OF THE VERTEBRAE. 

It will be convenient to divide fractures of the vertebrae into fractures 
of the spinous processes, transverse processes, vertebral arches, and 
bodies. 

§ 1. Fractures of the Spinous Processes. 

Fractures of the spinous apophyses, independent of a fracture of the 
arches, may occur at any point of the vertebral column ; and they may 
be occasioned by a blow received upon either side of the spinal column ; 
or by a force directed from above or from below. 

Symptoms and Pathology. — These accidents may be recognized by 
the lively pain at the point of fracture, produced especially when the 

1 Hunt, Amer. Journ. Med. ScL, April, 1866 

2 System of Surgery, Philadelphia ed., vol. i. p. 581, 1847. 



FRACTURES OF THE SPINOUS PROCESSES 



157 



Fig. 36. 




Fracture of the spinous process 



patient bends forwards, which position renders the skin and muscles tense 
and drives the fragments into the flesh ; by the swelling, tenderness, and 
discoloration ; but chiefly by. the lateral displacement of the broken pro- 
cess, and the mobility. 

Duverney met with a fracture of two of the processes in the same 
person, and which could only be recognized by the mobility, since, as 
the autopsy proved, there was no dis- 
placement. Nor would it be surprising if 
the displacement was absent in a majority 
of these accidents, inasmuch as the attach- 
ment of the ligaments from above and 
below with the strong and short muscles 
upon either side, must prevent a deviation 
in any direction until these tissues were 
more or less torn. Sir Astley Cooper men- 
tions a case in which, however, such lace- 
rations did occur, and the lateral defor- 
mity was quite conspicuous. 

A boy had been endeavoring to support 
a heavy weight upon his shoulders, when 
he fell bent double. Immediately he had 
the appearance of one suffering under a 
distortion of the spine of long standing. 
Three or four of the processes were broken off, and the corresponding 
muscles were detached so as to allow the processes to fall off to the 
opposite side. There was no paralysis, and he was soon discharged 
with the free use of his limbs, but the deformity remained. 1 

If the fragment is thrown directly downwards, as it possibly may be, 
especially in the cervical or lumbar region, yet not without a rupture of 
the supraspinous ligaments, or of the ligamentum nuchse, then the dis- 
placement will be more difficult to detect, and it may require some more 
care not to confound it with a fracture of the vertebral arch or of the 
plates from which the spinous processes arise. The process not being 
felt in its natural position, nor upon either side, it may seem to have been 
forced directly forwards, when in fact it is only thrown downwards to- 
wards its fellow. The danger of error in the diagnosis will be increased 
when to these conditions are added paralysis of those portions of the 
body which are beloAV the seat of the fracture, and which, in this case, 
may be the result of an extravasation of blood or of simply a concussion 
of the spinal marrow. Nor do I think it would be possible now to de- 
termine positively whether it was simply a fracture of a spinous process, 
of the arch, or of the body itself of the vertebra. In case, however, 
the paralysis results from concussion, the fact will in most cases soon 
become apparent by a return of sensation and of the power of motion. 

Prognosis. — Hippocrates affirmed that here, as in fractures of other 
spongy bones, the union took place speedily. It is quite probable that 
this venerable father of surgery has stated the fact correctly, and yet 
in the only example known to me where the condition of this process, 



1 Sir Astley Cooper, op. cit., p. 459. 



158 FRACTURES OF THE VERTEBRAE. 

as proved by dissection, has been carefully stated, the fragment had not 
united by bone at all. This is the case related by Sir Astley Cooper as 
having been examined by Mr. Key. A subject was brought into the 
dissecting-room', in which one of the processes had been broken, and, on 
dissection, a complete articulation was found between the broken sur- 
faces, which surfaces had become covered with a thin layer of cartilage. 
The false articulation was surrounded Avith synovial membrane and cap- 
sular ligaments, and contained a fluid like synovia. 1 

Ordinarily the displacement continues, whatever treatment may be 
adopted ; but Malgaigne says he has seen one instance in which the 
twelfth dorsal spine, being broken and displaced laterally, resumed its 
place spontaneously after a few days. Aurran mentions a similar ex- 
ample. 2 

Treatment. — If in any case it should be found possible to act upon 
the fragment, an attempt might be made to press it into place, and to 
retain it there by means of a compress and bandage ; but even this would 
not be admissible so long as any doubt remained whether it was not a 
fracture of the vertebral arch, since, if it were, any attempt to restore 
the bone to place by pressure would be likely to drive it more deeply 
upon the spinal marrow. Yet what need is there of surgical interference 
of any kind ? If the apophysis remains displaced it cannot result in any 
serious, perhaps we may say in any appreciable deformity. The surgeon 
has therefore only to lay the patient quietly in bed, and in such a posi- 
tion as he finds most comfortable, enjoining upon him perfect rest, and 
employing such other means as may be proper to combat inflammation. 

§ 2. Fractures of the Transverse Process. 

A fracture of a transverse process can scarcely occur except as a con- 
sequence of a gunshot wound. Dupuytren relates a case of this kind 
in which the ball had penetrated the transverse process of the second 
cervical vertebra. The man bled very little at the time, and his symp- 
toms progressed favorably for ten days ; after which secondary hemor- 
rhage occurred, of which he ultimately died. The autopsy showed that 
the vertebral artery had been injured, and that the inflammation of its 
coats being followed by a slough, caused his death. 3 

I have also elsewhere reported the case of Charles Harkner, of Buffalo, 
N. Y., who was shot with a pistol on the 21st of Jan. 1851. I did not 
see him until the following day. The ball had entered the chin, a little 
to the left side and below the inferior maxilla, but its place of lodgment 
could not be discovered. He lay with his face constantly turned to the 
right. The left side of his neck was swollen and crepitant ; the left arm 
and leg were paralyzed ; he slept most of the time, but could be easily 
aroused, and when aroused he seemed to be conscious, but was unable to 
speak. By signs he indicated to us that he w T as suffering no pain. He 
gradually sank, without hemorrhage, and died in thirty-six hours from 
the time of the receipt of the injury. 

1 Sir Astley Cooper, op. cit., p. 459. 2 Malgaigne, op. cit., p. 412. 

3 Dupuytren, Diseases, etc., of Bones, Syd. ed., p. 360. 



FRACTURES OF THE VERTEBRAL ARCHES 



159 



The autopsy, made four hours after death, enabled us to trace the wound 
from the chin, through the left ala of the thyroid cartilage, and also 
through the roots of the transverse process of the fourth cervical verte- 
bra ; immediately behind which, lying imbedded in the muscles, was the 
bullet. The cavity of the tunica arachnoides contained considerable 
serous effusion. 

The emphysema in the neck was occasioned, no doubt, by the wound 
of the larynx, the ball having opened freely into its cavity. This cir- 
cumstance also explained the aphonia ; but the immediate cause of his 
death seems to have been arachnoid effusion as a result of meningeal in- 
flammation. 

The symptoms arising from this accident can only refer to the compli- 
cations, since a mere fracture of the process is not likely to present 
any peculiar signs which could be recognized. Concussion or bloody 
effusion may take place so as to occasion more or less paralysis, or, at a 
later period, inflammation and its consequent effusions may give rise to 
the same phenomenon. 

In itself considered, and independent of these complications, it is suffi- 
ciently trivial, but inasmuch as it has not been known to occur except 
from gunshot w r ounds, nor is it likely to occur except from penetrating 
wounds of some kind, the accident must always be regarded as exceed- 
ingly grave, if not actually fatal. 

As to the treatment, nothing but strict rest and antiphlogistic rem- 
edies can prove of any service. 



§ 3. Fractures of the Vertebral Arches. 

The vertebral arches, upon which both the spinous and transverse 
processes have their principal support, may be broken at any point of 
their circumference, by a blow received upon the spinous process ; but 
generally it is the lamellar portion, or the 
"vertebral plate" which gives way rather Fig. 37. 

than the neck or pedicle of the arch ; and 
in all of the cases recorded the plates have 
been broken upon both sides. 

On the first of May, 1851, during a vio- 
lent storm of wind and rain, a balustrade 
fell from the top of a high building, strik- 
ing a man named John Larkin, who was 
about forty years of age, upon the back of 
his head and neck. He fell to the ground 
instantly, and did not again move his feet 
or legs, although he never lost his con- 
sciousness until he died. I found the blad- 
der paralyzed also, and his left arm, but 
his right arm he could move pretty w T ell. 
He conversed freely up to the last moment, 
and said that he was suffering a good deal of pain, which was always 
greatly aggravated by moving. His death took place thirty-six hours 
after the receipt of the injury. 




Fracture of the vertebral arch. 



160 FRACTURES OF THE VERTEBRAE. 

Dr. Hugh B. Vandeventer, who was the attending surgeon, made a 
dissection on the following day in my presence, which disclosed the fact 
that the plates of the sixth cervical vertebra were broken upon each 
side, and that the spinous process, with a small portion of the arch at- 
tached, was forced in upon the spinal marrow. There was no blood 
effused or serum at this point, but about one ounce of serum was found 
in the cavity of the tunica arachnoides at the base of the brain. The 
bodies of the vertebrae were not broken. It was our opinion, therefore, 
that the immediate cause of his death was the direct pressure of the 
spinous process. 

In the case related by Prout, of Alabama, the man having died within 
forty-eight hours after the receipt of the injury, the arch of the fifth cer- 
vical vertebra was found to be broken in three places, and the spinous 
process was driven in upon the spinal marrow. There was a slight 
effusion of blood between the sheath of the spinal marrow and the bone, 
and a considerable effusion between the sheath and the cord. There 
was no material lesion of the cord or of its membranes, and the body of 
the bone was neither broken nor dislocated. 1 

It is probable, also, that in the following example the arch was broken, 
but that the force of the blow having been somewhat oblique, the process 
was but little if at all thrown in upon the spinal marrow. 

R. L., of Erie County, N. Y., aged about forty years, was thrown 
from a loaded wagon in February of 1851, striking, as he' thinks, upon 
the back of his neck. He was stunned by the injury, and remained 
insensible several hours ; on the return of consciousness, he found that 
his lower extremities and bladder were paralyzed. During four weeks 
his bladder had to be emptied by a catheter. Nine months after the 
injury was received he consulted me, and I found the spinous process of 
the last cervical vertebra pushed over to the left side. His head was 
strongly bent forwards, and he was unable to straighten it. He could 
walk a few steps, but not without great fatigue ; and he suffered almost 
constant pain in his lower extremities, accompanied with excessive rest- 
lessness and watchfulness, for which he was obliged to take morphine in 
large quantities. 

In the case related by Alban G. Smith, of Kentucky, to which I shall 
refer again presently, the deviation was lateral, and so also in Ollivier's 
case, mentioned by Malgaigne. 

Symptoms. — We can imagine a case of fracture of the vertebral arch, 
with a lateral displacement only, in which the symptoms might not differ 
essentially from a simple fracture of the spinous process ; and it is quite 
possible that some of the cases which have been supposed to be exam- 
ples of this latter accident, and in which a speedy recovery has taken 
place, were really examples of fracture of the arches ; yet it must be 
admitted that such a fortunate result is only possible, since the arches 
can hardly be broken without communicating a severe concussion to the 
marrow, nor without lacerations, inflammation, and effusions, which will 
be most certain to produce compression and paralysis, and probably death. 

1 Prout, Amer. Journ. Med. Sci., Nov. 1837, vol. xxi. p. 276, from Western Journ. 
of Med. and Phys. Sci. 



FRACTURES OF THE VERTEBRAL ARCHES. 161 

If, however, it is possible for us to confound a fracture of the process 
with a fracture of the arches, it is still more possible for us to confound 
a fracture of the arches with a fracture of the bodies of the vertebrae. 
If, as is usually the fact, the process, incase of a fracture of the arch, 
is less prominent than natural, and that portion of the body receiving 
its nervous supply from below this point is paralyzed, we may have 
reasons to believe that the arch is broken and the process is driven in 
upon the spine ; but dissections have shown that in many of these cases, 
or in most of them, indeed, the bodies of more or less of the vertebrae 
are broken also, and in still other cases the bodies were alone broken. 

If, as in the case mentioned by Ollivier, we can feel the plates move 
separately, the diagnosis might be made out, so far at least as to deter- 
mine that the plates were broken ; but we should be still unable to say 
that the bodies of the vertebrae were not broken also. 

Something perhaps may be inferred from the direction and manner 
of the blow which has produced the fracture. Thus, a fall upon the top 
of the head would most often produce a comminution of the bodies by 
crushing them together, while a blow upon the back could scarcely break 
one of the vertebrae without breaking the corresponding arch also. We 
might thus be led to infer, in the first instance, that the arches were 
not broken ; and, in the second instance, if we could convince ourselves 
that the arches were not broken, we might rest pretty well assured that 
the bodies were not. 

In the case related by Prout, there was no external mark of injury 
over the point of fracture, but a distinct crepitus was perceptible on 
pressure. 

Treatment. — If the fragments are not displaced, nothing but rest and 
a cooling regimen are indicated ; but if they are forced in upon the mar- 
row, an important question is presented, and which has received from 
different surgeons different solutions. Shall an effort be made to reduce 
the fragments? and if so, by what means shall the indication be at- 
tempted ? 

It will be remembered that in nearly all of these cases we must re- 
main in doubt, even after the most careful examination, as to the actual 
condition of the fracture. It may be that what we suppose to be a frac- 
ture of the arch is only a fracture of the apophysis, or that, on the other 
hand, it is a fracture of the body of the bone itself; and if we are ex- 
pert enough to make out clearly a fracture of the arch, it is not possible 
for us to say that the body is not broken also, indeed it is quite probable 
that it is broken. With a diagnosis so uncertain, can we ever find a 
justification for surgical interference ? Mr. Cline and Mr. Cooper 
thought that we might. According to them, the case presents in no 
other direction a point of hope or encouragement. Death is inevitable, 
sooner or later, if the fragment is not lifted, and we can scarcely make 
the matter any worse by interference. If it proves to be a fracture of 
the apophysis, as happened to be the case in a patient upon whom Sir 
Astley operated, 1 our interference was unnecessary, but it has done no 
harm. If the body of the bone is broken, the operation affords no re- 

1 Chelius's Surgery, Amer. ed., note by South, vol i. p. 592. 



162 FRACTURES OF THE VERTEBKJ. 

sources, but the patient is probably beyond suffering damage at our 
hands. If the diagnosis is correctly made out and the arch only is 
broken, and if, as was the fact in the case of Larkin already mentioned, 
there is no bloody effusion, or laceration of the membranes or of the mar- 
row, and if the concussion was not sufficient to determine much inflam- 
mation of the cord, then it would seem possible that an operation might 
save the patient. 

Paulus iEgineta first suggested that the compressing fragments ought 
to be removed by excision ; and in 1762 Louis removed from a man who 
had received a gunshot wound in his back, after the lapse of five days, 
several loose pieces of bone belonging to the arch of the vertebra, and 
the patient recovered, but not without a partial paralysis of his lower 
extremities. Of course nothing could be more rational or simple than 
this procedure, adopted by Louis, in any case of an open wound, where 
the fragments could be easily reached ; but the younger Cline was the 
first, in the year 1814, to put into practice the more ancient suggestion 
of Paulus iEgineta, namely, to attempt the removal of the fragments in 
a case of simple fracture. He made an incision upon the depressed 
bones as the patient was lying upon his face, raised the muscles covering 
the spinal arch, removing, by means of a circular saw, chisel, mallet, 
and trephine, etc., the spinous processes of the eleventh and twelfth 
dorsal vertebrae, and the arch of one of the vertebrae. The patient was 
in no manner relieved, and died on the fourth day after the receipt of 
the injury and the third after the operation. 1 Mr. Oldknow repeated 
this operation in 1819 in a case of fracture of the arch of the seventh 
vertebra. The patient died on the sixth day. 2 In 1822, Mr. Tyrrell 
operated at St. Thomas's Hospital on a man who had been injured four 
days previously, removing the spinous processes of the twelfth dorsal 
and first lumbar vertebrae. The operation was accomplished with consid- 
erable difficulty, and resulted in only a partial return of sensibility. He 
died on the thirteenth day after the operation. 3 In 1827, Tyrrell ope- 
rated a second time, and death resulted on the eighth day. 4 On the 
30th of August, 1824, Dr. J. Rhea Barton, of Philadelphia, operated 
upon a man who had been received into the Pennsylvania Hospital 
twelve days before, with a fracture of the arch of the seventh dorsal 
vertebra. On the third day he was attacked with a violent chill, and 
death took place twelve hours after. The dissection showed about half 
a gallon of blood in the posterior mediastinum, and bloody effusion ex- 
isted along the whole length of the spinal canal. 5 The patient whom 
Laugier trephined at the base of the spinous process of the ninth dorsal 
vertebra, died on the fourth day. 6 The operation has been repeated 
unsuccessfully by Wickham, Attenburrow, Holscher, Heine, and Roux. 7 

February 5, 1834, Dr. David L. Rogers, of New York, operated upon 

1 Cline, Chelius's Surgery, Amer. ed., vol. i. p. 590. 

2 Sir A. Cooper on Disloc. and Frac, Amer. ed., 1851, p. 479. 

3 Sir A. Cooper's Loc, by Tyrrell, 3d Amer. ed., 1831, vol. ii. p. 17. 
* Med.-Chir. Rev., vol. x. p. 601. 

5 Barton, Goodman's ed. of Sir A. Cooper on Disloc, etc., p. 421. 

6 Malgaigne, Amer. ed., p. 341. 

7 Chelius's Surgery, Amer. ed., vol. i. p. 590. Also, Velpeau's Op. Surgery, 1st 
Amer. ed., vol. ii. p. 737. 



FRACTURES OF THE VERTEBRAL ARCHES. 163 

a man who had fallen two days before, breaking the arch of the first 
lumbar vertebra, and forcing the spinous process upon the cord. This 
man died on the eighth day. 1 

In 1854 Dr. Blackman, of Cincinnati, operated, his patient dying on 
the fourth day. During the same year, also, Dr. B. removed a portion 
of the sacrum for an injury of four years' standing, with no benefit. 2 
In 1858 Dr. Stephen Smith, of Bellevue, removed the arch of the tenth 
dorsal vertebra, death occurring soon after. 3 December 29, 1857, ten 
days after the receipt of the injury, Dr. J. C. Hutchinson, of Brooklyn, 
operated upon a man at the City Hospital, Brooklyn, removing the 
spinous processes of the eighth, ninth, and tenth dorsal vertebrae, with 
the posterior arch of the latter. The patient survived the operation ten 
days. 4 Ballingall says a Dr. Blair has operated successfully, but no 
particulars are given. 

Dr. H. A. Potter, of Geneva, N. Y., informs us that he has operated 
three times. In the first case he states that he removed the posterior 
portion of the three lower cervical vertebrae. The patient died on the 
fourth day. In the second case the doctor removed the spinous pro- 
cesses of the fifth and sixth cervical vertebrae, and the entire posterior 
arch of the fifth. The sheath was not broken, " but the cord was much 
injured." There was almost complete paralysis of the extremities, and 
this condition was not remedied by the operation. Three years later, 
the patient being still alive, but only a very slight improvement having 
taken place, Dr. Potter " removed the fourth, sixth, and seventh cervi- 
cal vertebrae." (We presume he intends to say the " posterior arches.") 
At the time of the report, Jan. 1863, there was no further improvement. 
Finally, the doctor reports a completely successful case. The injury 
was of "five months' standing." 5 Packard says, in a note to his trans- 
lation of Malgaigne, that Dr. Potter operated on a case of three months' 
standing, and the patient died on the eighteenth day. I suppose this 
to be the same case. 

These are all of the cases of which we have any information in which 
this operation has been made, and they have all, excepting the two cases 
reported by Potter and the one by Blair, terminated fatally in a very 
few days. The case reported by Alban Gr. Smith, of Kentucky, is not 
related in such a manner as to enable us to make use of it safely, nor is 
it stated how long the patient survived the operation ; Gibson says it 
gave no permanent relief. The example mentioned by an English writer 
is equally unreliable, inasmuch as it is given only upon rumor, and but 
a "few months" had elapsed since the operation was performed. It 
was said to have been made in the year 1838, by a surgeon of the name 
of Edwards, in South Wales ; and it was affirmed that the compression 
was relieved and that the patient " did well." 6 So unique a case would 

1 Rogers, Ainer. Journ. Med. Sci., May, 1835. 

2 Velpeau's Surgery, Blackmail's ed., vol. ii. p. 392. Also, Dr. Hutchinson's 
Paper, Trans. N. Y. St. Med. Soc, 1861. 

3 New York Journ. Med., 1859, p. 87. 

4 Hutchinson, Trans. N. Y. Med. Soc, 1861, p. 93. 

5 Amer. Med. Times, Jan. 10, 1863. 

6 Edwards, British and Foreign Med. Rev., 1838, p. 162. 



164 FRACTURES OF THE VERTEBRJE. 

certainly have found before this an ample confirmation. Indeed, we 
must say that none of the cases reported as successful give any evidence 
of authenticity. 

Experience, then, seems to have shown that we have little or nothing 
to expect from this surgical expedient; and, notwithstanding the strong 
hope expressed by Sir Astley Cooper that Mr. Cline's operation might 
hereafter prove a valuable resource, and contrary to the conclusions which 
we in common with many other surgeons had drawn from the anatomical 
relations of these parts, we are compelled reluctantly to declare that the 
expedient is scarcely worthy of a trial. To the same conclusion, also, 
many of the most distinguished surgeons have arrived, among whom we 
may mention, as especially entitled to confidence, Brodie, Liston, Alex- 
ander Shaw, Malgaigne, and Gibson. 

What more can be said of the attempt to raise the depressed bone by 
seizing the spinous process with the fingers, or with a pair of strong 
hooked forceps passed through the skin, or finally, if this cannot be 
done, by laying bare both sides of the process and seizing upon it with 
a pair of firm tenacula ? This is the alternative presented to Malgaigne, 
and which he ventures to recommend as deserving a trial. In the ab- 
sence, however, of any testimony in its favor, beyond the mere rational 
argument adduced by this distinguished writer, we must waive any 
further consideration of the subject ; only expressing our conviction that 
it will be found, after a fair trial, as useless and as inexpedient as the 
more severe operation of Cline. 

Jeffries Wyman, of Boston, has met with eleven examples of fractures 
of the vertebral arches occurring in the fourth or fifth lumbar vertebrae 
between the lower articulating and the transverse processes, all of them 
old ununited fractures. He has also met with the same fracture once in 
the third lumbar vertebra. The frequency of this peculiar form of frac- 
ture in this region Dr. Wyman ascribes to the fact that the upper and 
lower articulating processes are widely separated from each other, and 
connected only by a narrow neck, in which respect they contrast very 
strongly with the dorsal vertebrae ; and he supposes that the fractures 
may be caused by either a forcible bending of the body backwards, or 
by the shock resulting from a fall from a height in which the force of 
the concussion is conveyed downwards through the pelvis. In no case 
has the existence of this fracture been recognized during life, nor is it 
probable that its occurrence would cause any marked symptoms unless 
it had been caused by a blow received directly from behind. 1 

As to the therapeutical treatment of the various symptoms belonging 
to these accidents, and in relation to the prognosis, the remarks which 
we shall make will be found equally applicable to fractures of the bodies 
of the vertebrae, and we shall reserve the consideration of these topics 
for the following section. 



1 Wyman, Boston Med. and Surg. Journ., Aug. 12, 1869. 



FRACTURES OF THE BODIES OF THE VERTEBRAE. 165 

§ 4. Fractures of the Bodies of the Vertebrae. 

The same causes which produce fractures of the arches may produce 
also fractures of the bodies of the vertebrae, that is, blows received 
directly upon the extremities of the spinous processes ; but in these 
cases the arches are generally broken at the same time. 

In other cases the bodies of the vertebrae are broken by falls upon the 
top of the head, by which the vertebras are not only driven forcibly 
together, but often doubled forwards upon each other ; or the patient 
may have alighted upon his feet or upon his sacrum. 

Reveillon has reported a case of fracture of the fifth cervical vertebra 
from muscular action, which occurred in diving. The man was taken 
out of the water unconscious, and died in a few hours, having declared 
before death that his head did not strike the bottom, although he had 
jumped from a height of seven or eight feet, and the water was only 
three feet deep. 1 The statement of the sufferer, under such circum- 
stances, could not really possess much value, and we think we see good 
reason to suppose that he was mistaken. South also relates a case of 
fracture of the fourth and fifth cervical vertebrae occasioned by diving, 
in which it was supposed that the fracture was caused by the concussion 
of the head upon the water. 2 

Malgaigne says the spine bends at three principal points ; comprised, 
the first between the third and seventh cervical vertebrae, the second 
between the eleventh dorsal and second lumbar, the third between the 
fourth lumbar and the sacrum; and that a majority of the fractures of 
the vertebrae occur at these points of flexion. He makes an argument 
from this also that these fractures " are generally the result of counter- 
strokes, as the effect of forcible flexion of the column either forwards or 
backwards." Malgaigne observes, moreover, that dislocations follow the 
same rule. 

The direction of the line of fracture varies greatly in the different 
examples which we have seen ; some are crushed, and more or less com- 
minuted. In some cases a narrow piece is chipped from the margin, 
others are broken transversely, and others obliquely. In oblique frac- 
tures the line of the fracture is generally from behind forwards, and 
from above downwards. Malgaigne thinks that a crushing or comminu- 
tion can only occur from a forcible flexion forwards ; but I have seen at 
least one example in which this was not the fact ; the patient having 
fallen so as to strike with the back of his neck upon an iron bar. This 
was the case of the sailor, to which I shall again refer more particularly. 
The upper fragment is almost always that which suffers displacement ; 
sometimes being simply driven downwards, and thus made to penetrate 
more or less the lower fragment ; at other times, as in certain transverse 
fractures, it is only displaced forwards, and in still other examples, where 
the fracture is oblique, the upper fragment is displaced both downwards 
and forwards. 

In the first and last of these examples the spine becomes bent forwards 

1 Reveillon, Chelius's Surg., note bv South, vol. i. p 584. 

2 South, ibid., p. 583. 



166 



FRACTURES OF THE VERTEBRA. 



Fig. 38. 




Oblique fracture of the body of 
a vertebra. 



at the point of fracture, producing an angle of which the most salient 
point posteriorly is represented by the extremity of the spinous process 
belonging to the broken vertebra; in the second 
example the spinous process of the broken verte- 
bra is depressed, and the process of the vertebra 
next below is relatively prominent. 

In a pretty large proportion of cases also the 
fracture of the body of the vertebra is compli- 
cated, as we have already stated, with a fracture 
of the arches, in some instances with a fracture 
of the oblique processes, and with a dislocation. 
Symptoms. — Severe pain at the seat of frac- 
ture, felt especially when the part is touched or 
the body is moved, tenderness, swelling, ecchy- 
mosis, occasionally crepitus, a slight angular 
distortion of the spine, or simply a trifling irregu- 
larity in the position of the processes, and paraly- 
sis of all the parts whose nerves take their origin 
below the fracture, are the usual signs of the 
accident. 
The paralysis may be due to the mere pressure of the displaced frag- 
ments, but it is much more often due to a severe and irreparable lesion 
of the cord itself. I have, in one instance, seen the cord almost com- 
pletely separated at the point of fracture, although the displacement of 
the fragments was inconsiderable. 

Accompanying the paralysis of the bladder, there has been generally 
observed an alkaline state of the urine, and subacute inflammation of 
the coats of the bladder. Priapism is present in a certain proportion of 
cases. 

Those who die immediately seem to be asphyxiated ; while those who 
die later seem to wear out from general irritation, this condition being 
frequently accompanied with an obstinate diarrhoea and vomiting. A 
few become comatose before death. 

It will be seen, moreover, that a certain proportion finally recover ; 
but scarcely ever are all the functions of the limbs and of the body com- 
pletely restored. 

We shall render this part of our description of these accidents more 
intelligible if we regard them as they occur in the various portions of 
the spinal column, since the symptoms, prognosis, and treatment have 
reference mainly to the point at which the fracture has occurred. 



1. Fractures of the Bodies of the Lumbar Vertebral. 

The spinal cord terminates, in the adult, at the lower border of the 
first lumbar vertebra, but in the child at birth it extends as low as the 
third lumbar vertebra. The remainder of the vertebral canal is occu- 
pied by the leash of terminal nerves, called collectively the cauda equina. 

The nerves which emerge from the intervertebral foramina below the 
fourth and fifth lumbar vertebrae, unite with the sacral nerves to form a 
plexus which supplies the sphincter and levator ani, the perineal muscles, 



FRACTURES OF THE BODIES OF THE VEETEBRJ. 167 



the detrusor and accelerator urinae, the urethra, the glans penis, and a 
great proportion of the lower extremities. It will be apparent, there- 
fore, that a fracture, with displacement, of even the last vertebra of the 
column, involves the possibility of more or less paralysis of all those 
parts supplied by this plexus, and that in proportion as the fracture is 
higher in the vertebral column, will the probability of additional compli- 
cations be increased. In other words, in addition to the more or less 
complete loss of function in the organs supplied by the ilio-sacral plexus, 
there will probably be associated loss of function in other organs, sup- 
plied from sources above this point of the vertebral canal. 

A fracture, however, of the bodies of the fourth or fifth lumbar verte- 
bra, produced by a direct blow, is exceedingly rare, owing to the protec- 
tion which it receives from the alae of the pelvis. 

Dr. Alexander Shaw has reported four cases of fracture below the 
second lumbar vertebra, which were unaccompanied with any degree of 
paralysis, and which were followed by speedy recovery, 1 a circumstance 
which he ascribes to the fact that the cauda equina is composed of nerves 
possessing considerable firmness, and suspended loosely together ; for 
this reason they escape pressure by slipping among themselves, and suffer 
less injury from the same amount of compression than the medulla spi- 
nalis. 

In the two following cases the results were less fortunate, yet recov- 
eries seem to have taken place. 

A boy was admitted into St. George's Hospital, in September, 1827, 
with a fracture and considerable displacement of the third and fourth 
lumbar vertebrae, the displacement being sufficient to cause a manifest 
alteration in the figure of his spine. His lower 
limbs were paralyzed. An attempt was made to 
restore the displaced vertebras, but it was at- 
tended with only partial success. At the end of 
a month he had slight involuntary motions of the 
loAver extremities, and at the same time he began 
to recover the power of using them voluntarily. 
Three or four months after the receipt of the in- 
jury he left the hospital, and the history of his 
case was interrupted at this date. 2 

Dr. Thompson, of Goshen, N. Y., reports also 
a fracture of either the third or fourth lumbar 
vertebra, followed by recovery. The patient fell 
from the roof of a house, striking first upon his 
feet and then upon his buttocks. This occurred 
in October, 1853. The usual signs of a fracture 
were present, such as paralysis, etc. A bed-sore 
formed above the top of the sacrum, and a piece 
of bone exfoliated, which seemed to belong to 
the last lumbar vertebra. He was confined to 



Fig. 39. 




Key's case of fracture of the 
first lumbar vertebra. 



After eighteen months he began to use crutches. 



his bed seven months. 
At the end of about 



1 Shaw, London Med. Gaz., vol. xvii. 

2 Brodie, Sir Ast. Cooper on Disloc, op. cit., p. 471. 



168 FRACTUKES OF THE VERTEBRA. 

three years all improvement ceased, at which time he could not quite 
stand alone ; yet with the aid of apparatus he was able to get about the 
country and vend books, prints, etc. This was also his condition one 
year later. 1 

A patient in Guy's Hospital, under Mr. Key, with a fracture of the 
first lumbar vertebra, lived one year and two days. On examination 
after death it was ascertained that bony union had occurred between the 
fragments, and that the spinal marrow was completely separated at the 
point of fracture. 2 

Mr. Harrold relates a case of fracture of the first and second lumbar 
vertebrae, in which the patient survived the accident one year lacking 
nine days ; death having resulted finally from a sore on the tuberosity 
of the ischium and disease of the bone. After death it was ascertained 
that the fracture had united by bone, and that the spinal marrow was 
almost completely cut in two, the divided extremities being enlarged and 
separated nearly an inch from each other. 3 

2. Fractures of the Bodies of the Dorsal Vertebra?. 

In these examples the same organs are paralyzed as in the fractures 
lower down, in addition to which there is generally considerable disturb- 
ance of the functions of respiration, irregular action of the heart, indi- 
gestion, accompanied with a tympanitic state of the bowels. 

Dupuytren, who reports several examples of fractures of the dorsal 
vertebrae, has not taken the pains to record the length of time they sur- 
vived the accident except in two instances, both of which were fractures 
of the eleventh vertebra. One died of suffocation on the tenth day, and 
the other on the thirty-second. In Sir Astley Cooper's cases, mention 
is made of a fracture of the twelfth dorsal vertebra, which the patient 
survived fifty-two days, one of the tenth dorsal, which terminated fatally 
in six days, and another of the ninth dorsal, which did not result in death 
until after nine weeks. 

In 1853 Dr. Parkman presented to the Boston Society for Medical 
Improvement a specimen of fracture of the fifth dorsal vertebra, the 
bodies of the third and fourth being also displaced forwards, in which 
position they had become firmly ossified. The spinal cord had been com- 
pletely separated, yet the patient survived the accident two months. 4 

Dupuytren has related also two examples of fractures, one of the tenth 
and the other of the last dorsal vertebra, from which the patients com- 
pletely recovered after from two to four months' confinement. 5 A similar 
case is related by Lente, of New York. Barney McGuire, having fallen 
a distance of twelve or fifteen feet upon his back, was found with nearly 
complete paralysis of his lower extremities and of his bladder. Swell- 
ing existed over the lower dorsal vertebrae, and this point was very tender. 
Subsequently, when the swelling subsided, the prominence of the spinous 

1 Thompson, Amer. Journ. Med. Sci., Oct. 1857. Lente's paper. 

2 Key, A. Cooper on Disloc, etc., op. cit., p. 467. 

3 Harrold, A. Cooper, op. cit., p. 464. 

4 Parkman, New York Journ. Med., March, 1853, p. 286. 

5 Dupuytren, op. cit., pp. 356-7. 



FRACTURES OF THE BODIES OF THE VERTEBRAE. 169 

processes of the tenth and eleventh dorsal vertebrae put the question of 
a fracture beyond doubt. Gradually, under the use of cups, strychnia, 
mineral acids, laxatives, buchu, and electricity, his symptoms improved. 
In six months he was able to walk about the streets, and four years after 
the accident he was employed in a foundry under regular wages, being 
able to stand fifteen or twenty minutes at a time, and to walk half a mile 
without resting. At this time there remained no tenderness in the spine, 
but the projection of the process was the same as at first. 1 

3. Fractures of the Bodies of the five lower Cervical Vertebrce. 

We shall now have added to the symptoms already enumerated, paraly- 
sis of the upper extremities, greater embarrassment of the respiration, 
and more complete loss of sensation and volition in the lower part of the 
body. In general, also, the eyes and face look congested, owing to the 
imperfect arterialization of the blood, and death is more speedy and in- 
evitable. 

In ten recorded examples of fractures of the five lower cervical ver- 
tebrae which I have been able to collect, one died within twenty-four 
hours, four in about forty-eight hours, one in eleven days, one lived 
fifteen weeks and six days, one about four months, one fifteen months, 
and one, reported by Hilton, survived fourteen years. 2 The most com- 
mon period of death seems, therefore, to be about forty-eight hours after 
the receipt of the injury. 

The example of the patient who survived the accident fifteen weeks 
and six days, is recorded by Mr. Greenwood, of England. A woman, 
Mary Vincent, set. 47, was injured by a blow on the back of her neck, 
but she was not seen by Mr. Greenwood until after eleven days, at 
which time she was breathing with difficulty, occasioned by paralysis of 
the intercostal muscles, respiration being carried on by the diaphragm 
and abdominal muscles alone. This was the extent of the paralysis. 
There seemed to be a depression opposite the fourth and fifth cervical 
vertebrae, and pressure at this point occasioned universal paralysis, as 
did also the action of coughing and sneezing. About three weeks after 
the accident, she attempted for the first time to move in order to have 
her clothes changed, when she was immediately seized with paralysis in 
the right arm and hand. After this she lost her appetite, had frequent 
attacks of purging, and thus she gradually wore out. 3 

The patient who survived about four months was admitted into Hotel 
Dieu, under the care of Dupuytren, in 1825, on account of a fracture 
of the fourth cervical vertebra, caused by a fall on the back of his neck, 
and suffering under paralysis of the bladder and extremities. After 
two months and a half of entire rest, he was convalescent, and quitted 
the hospital, with only slight weakness in his left leg, and with his head 
a little bowed forwards. In returning from a long walk he fell para- 
lyzed, and remained in the open air all night. From this time he con- 
tinued to fail, and died thirty-four days after the second fall. On 

1 Lente, Amer. Journ. Med, ScL, Oct. 1857, p. 361. 

2 Hilton, Lond. Lancet. Oct. 27, 1860. 

3 Greenwood, Sir A. Cooper on Disloc, p. 472. 
12 



170 FKACTURES OF THE VERTEBRAE. 

examination after death, the body of the vertebra was found to be broken, 
and also the processes of the fifth, allowing the fourth to slip forwards 
and compress the cord. A true callus existed in front of these bones, 
which looked as if recently broken. The cord itself exhibited an an- 
nular constriction, which Dupuytren conceived to be the seat of the 
original lesion narrowed by cicatrization. 1 

The following example furnishes a fair illustration of the usual phe- 
nomena which accompany fractures of the third or fourth cervical ver- 
tebra. 

On the 25th of July, 1857, a sailor fell backwards from the wharf, 
striking with the nape of his neck upon a bar of iron. I saw him on 
the following day, in consultation with his attending physician, Dr. 
Edwards. He was lying upon his back, breathing rapidly. His lower 
extremities were completely paralyzed ; legs and feet swollen and pur- 
ple ; right arm completely paralyzed, and his left partially ; from a point 
below the line of the second rib, there was no sensation whatever; his 
bowels had not moved, although he had already taken active cathartics ; 
the urine had been drawn with a catheter ; the pulse was slower than 
natural, and irregular. He was constantly vomiting. In reply to 
questions, he said that he felt well, articulating distinctly, and with a 
good voice. His eyes and face were somewhat congested, but with this 
exception his countenance did not betray the least physical disturbance. 
He lived in this condition about forty hours, only breathing shorter and 
shorter, and his consciousness remaining to the last moment. 

In proceeding to examine the spine a few hours after death, and 
before any incision was made, we were unable, upon the most minute 
examination, to detect any irregularity of the processes of the cervical 
vertebrae, or any crepitus; but, on dissecting the neck, we found that 
the arches of the third and fourth vertebrae were broken, and the spinous 
processes slightly depressed upon the cord. The bodies of the cor- 
responding vertebrae w T ere comminuted, and the vertebrae above w T ere 
driven down upon them, carrying the processes in the same direction. 
The theca and the spinal marrow were almost completely severed upon 
a level with the fourth vertebra. 

A man residing in Erie Co., N. Y., was thrown backwards suddenly 
from the back end of a wagon, alighting upon the top of his head. Dr. 
Mixer having requested me to see this patient with him, I found the 
symptoms almost an exact counterpart of those which belonged to the 
case which I have just described, except that a crepitus and a mobility 
of the fragments could be distinctly felt in the upper and back part of 
his neck. His death occurred in very much the same manner after 
about forty-eight hours. No autopsy was allowed. We noticed in this 
case, also, that whenever he was turned over upon his face, respiration 
almost entirely ceased, but it was immediately restored by laying him 
again on his back. Many other similar examples have from time to 
time come under my notice. 

Strains of the Ligaments and Muscles. — Dupuytren, Sir Astley 
Cooper, South, and other surgeons have related cases simulating fracture, 

1 Dupuytren, op. cit., p. 358. 



FRACTURES OF THE BODIES OF THE VERTEBRJ. 171 

but which proved to be strains of the ligaments uniting the cervical ver- 
tebrae, accompanied with more or less injury to the spinal marrow. In 
one instance, I have met with what has seemed to be a strain of the 
ligaments and muscles of the neck, but which presented no symptoms of 
serious injury to the spinal marrow. 

John Neuman, of Canada West, aet. 25, fell headforemost from a 
height of fourteen feet, striking upon the top of his head. He was 
taken up insensible, and remained in this condition six hours. When 
consciousness returned, his head was very much drawn backwards, and 
it was impossible to move it from this position. There was no lack of 
sensibility or of the power of motion in his limbs, and all the functions 
of his body were in their natural state ; but he has suffered with occa- 
sional severe pains in his arms ever since. The accident happened on 
the twenty-fourth of November, 1857, and he called upon me eight 
months after. His head was then forcibly bent forwards instead of 
backwards, into which position it had gradually changed. In the morn- 
ing he generally was able to erect his head completely, but after a few 
hours it was constantly drawn forwards, as when I saw him. There 
was no tenderness or irregularity over the cervical vertebrae, and he was 
so well as to be regularly employed as a day-laborer. 

Concussion. — Sir Astley Cooper has collected four examples of what 
he terms " concussion of the spinal marrow," all of which recovered 
after periods ranging from a few weeks to many months ; but in only 
one case is it stated that the recovery was complete. 1 Boyer also enu- 
merates three cases of concussion which came under his own observation, 
all of which terminated fatally in a short time. In the first example 
mentioned by Boyer, the autopsy disclosed neither lesion nor effusion of 
any kind ; in the second case, it does not appear that any autopsy was 
made. The third is related as follows: " A builder fell from a height 
of fourteen feet, and remained for some time senseless ; and, on recov- 
ering from that situation, found that he had lost the use of his inferior 
extremities. He had at the same time a retention of urine, an involun- 
tary discharge of the feces, and some disorder in the function of respira- 
tion. Death followed on the twelfth day after the accident. The body 
was opened, and the vertebral canal was found to contain a sanguineous 
serum, the quantity of which was sufficient to fill a little more than its 
lower half.." 2 No doubt some of the cases reported as concussion were 
only examples of paralysis from extravasation of blood, a circumstance 
which is peculiarly likely to happen as a result of the rupture of one of 
those numerous large vessels which surround the vertebrae outside of the 
thecae. It is seldom that the vessels of the cord itself give out sufficient 
blood in these cases to cause compression. Possibly examples of com- 
pression as a result of extravasation of blood may sometimes be recog- 
nized by the fact of the gradual approach of the paralysis after the lapse 
of several hours, as has occurred recently in a case brought to my notice 
at the Belle vue Hospital, and in which recovery finally took place. 

1 Sir A. Cooper, op. cit.. p. 454. 

2 Boyer, Lecture on Diseases of the Bones, Amer. ed., 1805, p. 55. 



172 FRACTURES OF THE VERTEBRAE. 

4. Treatment of Fractures of the Bodies of the Vertebral when the frac- 
ture occurs in any portion of the column beloiv the Second Cervical. 

In a few instances, I have noticed among the recorded examples of 
fractures of the bodies of the vertebrae, that surgeons have made some 
slight attempt to reduce the fracture, or rather to rectify the spinal dis- 
tortion, generally by the application of moderate extension to the limbs, 
and by laying the patient horizontally upon a hard mattress. But I 
have not been able to discover that in any case the patients have de- 
rived benefit from the attempt, although it has been said occasionally, 
by the gentleman making the report, that the deformity was slightly 
diminished. Nor am I aware that in any instance the patient has suf- 
fered any damage from the attempt ; at least the reporter has in no case 
thought it necessary to make this observation. I am confident, however, 
that such manipulation can seldom serve any useful purpose, and I very 
much fear that it has been frequently a source of mischief ; although in 
cases so generally fatal, it might be very difficult to estimate with much 
accuracy the amount of injury done. If by any possibility the frag- 
ments could be replaced, I know of no means by which they could be 
kept in place ; and in truth we are much more likely to increase the 
penetration of the spinal cord and the general disturbance, than to dimin- 
ish it, by extension or pressure. Moreover, it usually inflicts upon the 
unfortunate sufferer great pain, and for these reasons it ought generally 
to be discouraged. 

I have, however, met with two cases of fracture of the lumbar verte- 
brae, in which relief was afforded by permanent extension. When the 
fracture is below the middle of the vertebral column, extension, if em- 
ployed, should be made by adhesive straps, weights, and a pulley, as 
will hereafter be directed in fractures of the femur ; the counter-exten- 
sion being made by the weight of the body. It will be understood, 
however, that when paralysis exists the ligation of a limb with bandages 
will expose the patient to great danger of ulceration and sloughing at 
and below the points of pressure, and the amount of extension must be 
very moderate. 

When treating of fractures of the arches of the vertebrae, I took occa- 
sion to call attention to Mr. Cline's operation, occasionally recommended 
and practised in such cases. I was not ignorant, however, that Mr. 
Cline, and several other of the advocates of this operation, had recom- 
mended it especially for fractures of the bodies of the vertebrae when 
accompanied with displacement. Even Malgaigne has preferred to con- 
sider the merits of this operation in its relations to these latter fractures; 
but while I am prepared to admit the propriety of an argument as to the 
value of Cline's operation considered in reference to fractures of the 
arches, I cannot admit its propriety in reference to fractures of the 
bodies of . the vertebrae. The proposition appears to me too absurd to 
be entertained for a moment. 

The treatment, then, ought to be, in a great measure, expectant. The 
patient should be laid in such a position as he finds most comfortable, 
and, as far as possible, the spine should be kept at rest, since the most 
trivial disturbance of the fragments, and even that which may cause no 



FRACTURES OF THE BODIES OF THE VERTEBRAE. 173 

pain to the patient, is liable to increase the injury to the spine, and pre- 
vent the formation of a bony callus. Especially ought the surgeon to 
be careful, while making the examination, not to turn the patient upon 
his face, in which position the spine loses its support and a fatal pressure 
may be produced. The urine should be drawn very soon after the acci- 
dent, and at least twice daily for the next few weeks. Indeed, it is a 
better rule to draw the urine as often as its accumulation becomes a 
source of inconvenience, or whenever the bladder fills, which will in some 
cases be as often as every four or six hours. It is especially necessary 
to attend to those urgent demands of the patient during the first few 
weeks, when the paralysis is most complete generally, and the mucous 
surface of the bladder, already irritated and inflamed by the excessively 
alkaline urine, suffers additional injury from any degree of painful dis- 
tension of its walls. It is unnecessary to say that the frequent introduc- 
tion of the catheter may itself prove a source of irritation, until it is 
managed carefully and skilfully. This duty ought never to be intrusted 
to an inexperienced operator. 

I do not see what advantage the surgeon can expect to derive from the 
administration of drastic purgatives, such as full doses of jalap, castor 
oil, or spirits of turpentine, at any period. If in the first instance the 
bowels are so completely paralyzed that they seem to demand such 
violent measures to arouse them to action, we may be quite certain that 
the spinal cord is suffering from a pressure, or from some lesion, which 
these agents have no power to remedy. The bowels may possibly be 
made to act, but it would be difficult to show how this is to relieve the 
suffering cord. So far from affording relief, these measures add directly 
to the nervous irritation and prostration, provoke vomiting and general 
restlessness. It is not desirable, we think, to obtain a movement of the 
bowels, during the first few days by any means, however gentle. The 
effort to defecate, and the consequent motion, will probably do much 
more harm than the .evacuation can do good ; and especially, for the 
same reason, ought Ave to avoid putting into the stomach anything which 
will occasion nausea and vomiting. 

After the lapse of a few days, if reasonable hopes begin to be enter- 
tained of a recovery, it will become important to establish regular evacu- 
ations of the bowels, either by a judicious management of the diet, by 
gentle laxatives, or by enemata. At a still later period, when the in- 
flammatory stage is past, and the nerves remain inactive or paralyzed, 
nothing could be more rational than the employment of strychnia in doses 
varying from the one-twelfth to the one-eighth of a grain three times 
daily. Nor do I think that any single remedy has more often proved 
useful in my own practice, or in the practice of other surgeons with 
whom I am acquainted. In order, however, to derive benefit from this 
or any other remedy, it must be continued for a long time ; perhaps for 
a year or more. Electricity, setons, issues, and blisters are no doubt 
also sometimes useful. Care must be taken that setons, etc., do not pro- 
duce bed-sores. Passive motion and frictions, good fresh air, and nour- 
ishing diet, become at last essential to recovery. From an early period 



and during the whole course of the treatment, great attention should be 



174 FRACTURES OF THE VERTEBRA. 

paid to the prevention of bed-sores, by supporting all those parts of the 
body upon which the pressure is considerable. For this purpose we may 
employ circular cushions, air-cushions, and air-beds ; but water-beds are 
very much to be preferred to air-beds as a means of preventing bed-sores. 
Water-beds must be filled with water at the temperature of 68° Fahren- 
heit, and they must be secured in position by side boards, or a kind of 
shallow box, the sides of which are elevated six or seven inches. Per- 
manent extension can be employed upon these beds as well as upon ordi- 
nary beds. Sometimes a section of a bed, three feet square, is found 
quite as serviceable as an entire bed, inasmuch as the back and nates 
are the only parts which are liable to bed-sores. They may be obtained 
from the manufacturers, Hodgman & Co., corner of Nassau Street and 
Maiden Lane, New York City, at prices ranging from $15 to $25. Of 
late we have found the wire-beds, manufactured at 59 Pearl Street, Hart- 

Fig. 40. 




Wire-bed. 



ford, Conn., excellent substitutes for water-beds. They are less expen- 
sive, more easily managed, more durable, and admit of a much better 
regulation of the temperature. Whether they are quite as efficient in 
the prevention of bed-sores as water-beds, I cannot say positively, but 
they have been much used under my observation at Bellevue and in the 
Hospital for Ruptured and Cripples, and I have seen no bed-sores occur 
where they were in use. 

When sores have formed, they should be treated, if sloughing, with 
yeast poultices, or the resin ointment. I find also the resin ointment an 
excellent dressing for the sores after the sloughs have separated. In 
case the surface is only slightly abraded, simple cerate forms the best 
spplication. 

§ 5. Fractures of the Axis. 

The phrenic nerve is derived chiefly from the third and fourth cervi- 
cal nerves. If, therefore, the second cervical vertebra is broken, and 
considerably depressed upon the spinal cord, respiration ceases imme- 
diately, and the patient dies at once, or survives only a few minutes. 
In such examples of fracture of this bone as have not been attended 
with these results, the displacement and consequent compression have 
been considerable, or there has been no displacement at all. 

Mr. Else, of St. Thomas's Hospital, says that a woman in the vene- 
real ward, and who was then under a mercurial course, while sitting in 
bed, eating her dinner, was seen to fall suddenly forwards ; and the 
patients, hastening to her, found that she was dead. Upon examination 
of her body, it was discovered that the processus dentatus of the axis 



FRACTURES OF THE AXIS. 175 

was broken off, and that the head in falling forwards had driven the pro- 
cess backwards upon the spinal marrow so as to cause her death. 1 

Sir Astley Cooper also relates the case of a man who was shot by a 
pistol through the neck, breaking and driving in upon the spinal marrow 
both the "lamina and the transverse process" of the axis. He died on 
the fourth day. 2 

Malgaigne has collected three cases of fracture of the odontoid apo- 
physis, all of which were accompanied with displacement of the atlas. 
The first, reported by Richet, died on the seventeenth day ; the second, 
reported by Palletta, died after one month and six days ; and the third, 
by Costes, lived four months and two weeks. 

Rokitansky says that there is a specimen contained in the Vienna 
Museum, taken from a patient who survived the accident some time, al- 
though the fragments never united. 

The following case is reported by Parker: — 

" The patient, Mr. G. B. Spencer, was a man forty years of age, a 
milkman by occupation, of medium height, nervo-sanguine temperament, 
of active business habits, and capable of great endurance. His life was 
one of constant excitement, and he was addicted to the free use of liquors. 
He suffered, however, from no other form of disease than occasional 
attacks of rheumatism, for which he was accustomed to take remedies of 
his own prescribing, which were generally mercurials followed by liberal 
doses of iodide of potassium, ' to work it all out of the system.' 

"On the 12th of August, 1852, while driving a 'fast horse' at the 
top of his speed on the plank road near Bushwick, L. I., he was thrown 
violently from his carriage by the wheel striking against the toll-gate. 
He alighted upon his head and face about fifteen feet from the carriage. 
Upon rising to his feet he declared himself uninjured, but soon after 
complained of feeling faint ; after drinking a glass of brandy he felt 
better, got into his carriage with a friend, and drove home to Rivington 
Street in this city, a distance of more than two miles. There was so 
little apparent danger in this case, that no physician was called that 
night. Early on the morning of the following day, Dr. B. was called 
to visit him. He found his patient reclining in his chair, in a restless 
state, and learned that he had suffered considerable pain in the back 
part of his head and neck during the night. He was entirely inca- 
pacitated to rotate the head, which led to the suspicion of some injury 
to the articulations of the upper cervical vertebne ; but so great a de- 
gree of swelling existed about the neck as to prevent efficient examina- 
tion. There was no paralysis of any portion of the body, his pulse was 
about 90, and his general system but little disturbed. Warm fomenta- 
tions were applied to the neck, and a mild cathartic administered. On 
the following day there was no particular change in his symptoms, but 
as there existed considerable nervous irritability, tinct. hyoscyami was 
prescribed as an anodyne, and fomentations of hops applied locally. 
On the third day, leeches were applied to the neck, and after this the 
swelling so much subsided, that on the fifth day an irregularity was dis- 

1 Else, Sir A. Cooper on Disloc., etc., op. cit., p. 462. 

2 Sir A. Cooper on Disloc, etc., op. cit., p. 476. 



176 FRACTURES OF THE VERTEBRAE. 

covered to exist in the region of the axis and atlas, which had many of 
the features of a partial luxation of these vertebrae. 

" At this time he began to walk about the room, having previously 
remained quiet on account of the pain he suffered on moving. He per- 
sisted in helping himself, and almost constantly supported his head with 
one hand applied to the occiput. He often remarked, if he could be 
relieved of the pain in his head and neck, he should feel well. He 
began to relish his food, and the swelling nearly disappeared at the end 
of a week, leaving a protuberance just below the base of the occiput, to 
the left of the central line of the spinal column, with a corresponding 
indentation. Notwithstanding strict orders to remain quietly at home, 
on the ninth day after the accident he rode out, and in a day or two 
after returned as actively as ever to his former occupation of dis- 
tributing milk throughout the city to his old customers. During the 
following four months no material change took place in his symptoms, 
although he constantly complained of pain in his head. For this period 
he did not omit a single day his round of duties as a milkman, which 
occupied him constantly and actively from five o'clock in the morning to 
nearly noon. On the first of November, Prof. Watts examined him, 
and inclined to the opinion that there was a luxation of the upper cer- 
vical vertebrae. 

"About the 1st of January, 1853, the pains, from which he had been 
a constant sufferer, became more severe, and he was heard to complain 
that he could not live in his present condition ; he remarked, also, that 
he had heard a snapping in his neck. After going his daily round on 
the 11th of January, he complained of feeling cold, and afterwards of 
numbness in his limbs. In the evening he had a chill, and complained 
of a pain in his bowels. He passed a restless night, and arose on the 
following morning about six o'clock; he was obliged to have assistance 
in dressing himself, and experienced a numbness of his left, and after- 
wards of his right side. He attempted to walk, but could not without 
help, and it was observed that he dragged his feet. He sat down in a 
chair and almost instantly expired, at eight o'clock A. M., on the 12th 
of January, precisely five months from the receipt of the injury. 

" The autopsy was made thirty hours after death, by Dr. C. E. 
Isaacs, in presence of several medical gentlemen. Muscular develop- 
ment uncommonly fine. An unusual prominence discovered in the 
region of the axis and atlas. On making an incision from the occiput 
along the spines of the cervical vertebrae, the parts were found to be 
very vascular. These vertebrae were removed en masse, and a careful 
examination instituted. The transverse, the odontoid (ligamenta mode- 
ratoria), as also all the ligaments of this region, excepting the occipito- 
axoideum, were in a state of perfect integrity ; this latter was partially 
destroyed. A considerable amount of coagulated blood was found effused 
between the fractured surfaces, some of it apparently recent, but much 
of it was thought to have occurred at the time of the accident, and after- 
wards to have prevented the union of the bones. The spinal cord exhi- 
bited no appearances of any lesion. The odontoid process was found in 
the position well represented in the accompanying illustration, completely 
fractured off, and its lower extremity inclining backwards toward the cord. 




FRACTURES OF THE AXIS. 177 

Death finally took place, doubtless, from the displacement of the process 
during some unfortunate movement of the head, by which pressure was 
made upon the cord. The destruction of the 
occipito-axoid ligament, which would otherwise 
have protected the contents of the spinal cavity, 
must have favored this result." 1 

Dr. Philip Bevan presented to the Surgical 
Society of Ireland, in 1862, a specimen obtained 
from the dead-room, and which was supposed to 
be an epiphyseal separation of the odontoid pro- 
cess, occurring in early life. The history of the 
case is not known, although the woman was forty 
years old when she died. It does not appear 
very clear to us whether this was really an epi- 
physeal separation, or the result of some morbid 
process. 2 

At the meeting of the New York Pathological Fracture of the odontoid 
Society, Nov. 12, 1868, Dr. Austin Flint pre- process of the axis. Parker's 
sented a case of separation of the odontoid pro- !" e * A ; Broken surface - B - 

- l Odontoid process. 

cess ot the axis. 

Dr. W. Bayard, of St. John, N. B., has, however, reported a case of 
separation of the odontoid process in a child, followed by complete re- 
covery. In August, 1861, Charlotte Magee, of St. John, set. 6 years, 
previously in excellent health, fell five feet, striking on her head and 
neck, causing an immediate immobility of the head, which continued 
about two years and a half, when an abscess formed in the back of the 
pharynx, and the bone was spontaneously discharged. Since then she 
has been able to move the head freely, and her recovery may be said to 
be complete. 3 The specimen was subsequently presented to the New York 
Pathological Society, and no doubt remains that the entire process was 
thrown off. 

Dr. Stephen Smith, who has written a very instructive paper on this 
subject, has collected 23 cases of separation of the odontoid process, at 
least 20 of which must be regarded as fractures. The ages of the 
patients range from three years to sixty-eight. Eight of this number 
were spontaneous, the separation being apparently due to some progres- 
sive disease or atrophy of the bone. Two of these recovered after the 
formation of abscesses in the pharynx and the extrusion of the bone. 
In four cases the fractures were gunshot, and one died. The remainder, 
so far as ascertained, were in consequence of blows upon the head ; and 
of these only the girl Charlotte Magee recovered. Of the whole num- 
ber, 23, three were without history, two of them being dissecting-room 
cases. 4 

Symptoms. — These will depend much upon the cause and complica- 
tions of the accident. In all cases there will be more or less inability 

1 Bigelow, New York Journ. Med., March, 1853, p. 164. 

2 Bevan, Ainer. Journ. Med. Sci., April, 1864. From Dublin Med. Press, Feb. 18, 
1863. 

3 Bayard, Canada Med. Journ., Dec. 1869. 

4 Smith, Amer. Journ. Med. Sci., Oct. 1871, p. 338. 



178 FRACTURES OF THE VERTEBRAE. 

to support the head in the erect posture, and if displacement exists, or 
if the products of inflammation form upon the cord, a proportionate im- 
pairment of its functions must ensue. 

Treatment.— The treatment consists in absolute quietude, with mode- 
rate extension, effected by means of suitable apparatus. 

§ 6. Fractures of the Atlas. 

I have been able to find only one example of a fracture of the atlas 
alone, and this is the case related by Sir Astley Cooper as having come 
under the observation of Mr. Cline. 

A boy, about three years old, injured his neck in a severe fall ; in 
consequence of which he was obliged to walk carefully upright, as per- 
sons do when carrying a weight on the head ; and when he wished to 
examine any object beneath him, he supported his chin upon his hand, 
and gradually lowered his head, to enable him to direct his eyes down- 
wards. In the same manner, also, he supported his head from behind 
in looking upwards. Whenever he was suddenly shaken or jarred, the 
shock caused great pain, and he was obliged to support his chin with his 
hands, or to rest his elbows upon a table, and thus support his head. 
The boy lived in this condition about one year, and after death Mr. Cline 
made a dissection, and ascertained that the atlas was broken in such a 
manner that the odontoid process of the axis had lost its support, and 
was constantly liable to fall back upon the spinal marrow. 1 

§ 7. Fractures of the first two Cervical Vertebrse (Atlas and Axis) at the 

same time. 

A woman, set. 68, fell down a flight of steps, striking upon her fore- 
head, and died immediately. Upon making a dissection, it was found 
that the atlas was broken upon both sides near the transverse processes, 
and the odontoid process of the axis was broken at its base. These frac- 
tures were accompanied with a rupture of the atloido-odontoid ligaments, 
and a dislocation of the atlas backwards. 2 

South says there is a specimen in the museum of St. Thomas's. Hos- 
pital, showing this double fracture. The man had received his injury 
only a few hours before admission to the hospital, and died on the fifth 
day. On examination, the atlas was found to be broken in two places, 
and the odontoid process of the axis at its root. The fifth vertebra was 
also broken through its body. With neither fracture was there sufficient 
displacement to produce pressure, but a small quantity of extravasated 
blood lay in the substance of the spinal marrow, and its tissue was at 
one point broken down and disorganized. 3 

Mr. Phillips relates that a man fell from a hay-rick, striking upon the 
occiput ; after which, although momentarily stunned, he walked half a 
mile to the parish surgeon, and in two days more he returned to his oc- 
cupation. About four weeks after the accident he was seen by Mr. 

1 Cline, Sir Astley Cooper, op. cit., p. 459. 

2 Malgaigne, op. cit., torn. ii. p. 333. 

3 Chelius's Surgery, note by South, vol. i. p. 588. 



FRACTURES AND DIASTASES OF THE STERNUM. 179 

Phillips, who discovered a small tumor over the second cervical vertebra, 
pressure upon which caused a slight pain. He complained also that his 
neck was stiff, and that he was unable to rotate it. No other disturbance 
of the functions of the body could be discovered. After a time the 
tonsils became swollen, and the patient experienced some difficulty in 
deglutition, and, upon examining the throat, a slight projection or fulness 
was discovered at the back of the larynx, opposite the second cervical 
vertebra. Subsequently he became affected with general anasarca and 
pleuritic effusions, of which he finally died. Up to the last week of his 
life he was able to walk about his bedroom, and his condition presented 
no other evidence than has been mentioned, that he was suffering from 
an injury of the spine. He died forty-seven weeks after the receipt of 
the injury. 

The autopsy disclosed a fracture with displacement of the atlas, and 
a fracture of the odontoid process of the axis. The two vertebras were 
united to each other firmly by complete bony callus. 1 



CHAPTEE XVII. 



FRACTURES AND DIASTASES OF THE STERNUM. 



Fig. 42. 



Fractures and diastases of the sternum are of rare occurrence, owing, 
probably, to the elasticity of the ribs and their cartilages, upon which 
it mainly rests, and also, in part, to the softness of its structure. In 
advanced life, the ossification and fusion of all of its several portions 
becoming more complete, and the cartilages of the ribs also becoming 
more or less ossified, a true frac- 
ture is relatively more frequent. 

In some cases no doubt these 
accidents ought to be regarded as 
true luxations, inasmuch as occa- 
sionally the union of the manu- 
brium with the gladiolus is by a 
perfectly-formed diarthrodial ar- 
ticulation, as was first demon- 
strated by Maisonneuve in 1842. 
We have, however, in general 
no absolute means of knowing 
whether before the accident the 
several portions which compose 
the sternum were united by bone, 
by a single piece of cartilage, or 
by two distinct cartilages with a 
synovial surface interposed ; and 




vctT-fli/ unite , 

3S-//0. 
10-25$ year 



soon after puberty 



ly curtUla-gittcus i.i% 

adi/awed life 

Sternum, showing the periods at which its several 
parts unite by bone. (From Gray.) 



Phillips, Med.-Chir. Trans., vol. xx. 1837, p. 384. 



180 FRACTURES AND DIASTASES OF THE STERNUM. 

inasmuch as the causes, symptoms, and treatment must be essentially 
the same in either case, it seems unnecessary to consider these luxations 
separately, as Malgaigne, Yidel (de Cassis), and others have done. 

Causes. — They are generally the result of direct blows inflicted upon 
the part, such as the passage of a loaded vehicle across the chest, the 
fall of a tree or of some heavy timber upon the body ; the fracture im- 
plying always that great force has been applied. 

Indirect blows and voluntary muscular action alone have been known 
also occasionally to produce these accidents. 

David, in his Memoir e sur les Contrecoups, published as a prize essay 
by the Academy of Medicine, mentions the case of a mason, who, in 
falling from a great height, struck upon his back against a cross-bar 
which intercepted his fall, in consequence of which the abdominal and 
sterno-cleido-mastoiclean muscles were so stretched that the sternum 
broke asunder between its upper and middle portions. 1 Sabatier reports 
another case of separation at the same point, produced in a similar man- 
ner ; 2 and Roland has described a third example in a woman sixty-three 
years old, who, falling from a height backwards and striking upon her 
back, broke the sternum near its centre. 3 Gross and Hodgen have 
recorded similar cases. 4 

Cruveilhier saw a man who, having fallen from a height of twenty feet 
upon his nates, was found to have a fracture of the sternum. 5 Cussan 
saw the same result in a person who fell from a third story, striking first 
upon his feet and then pitching over upon his back. 6 Maunoury and 
Thore have reported an analogous case, where a man fell from a height 
of twelve or fifteen metres, first striking upon his feet and then falling 
over upon his back and head. 7 

Mr. Johnson, late editor of the London Med.-Chir. Rev., reports a 
case as having been received into St. George's Hospital, in which the 
man, a healthy laborer from the country, had fallen from the top of a 
hay-cart, striking only upon his head. He walked with his head much 
bent forwards, and was incapable of either flexing, extending, or rotating 
it any farther. The fracture was transverse, and about three inches 
below the top of the sternum, opposite the centre of the third rib, the 
lower fragment projecting in front of the upper. The fragments were 
easily replaced by simply throwing the head back, and fell into place 
with an audible snap, but immediately resumed their unnatural position 
when the head was flexed. They finally united, but with a slight pro- 
jection and overlapping. 8 

Malgaigne expresses a doubt whether all these can be considered as 
the results of muscular action, since, in a certain number of the exam- 
ples cited, the head seems to have been thrown forwards by the concus- 

1 Boyer on Bones, p. 57. 

2 Malgaigne, from Sabatier, Mem. sur la Fract. du Sternum. 

3 Ibid., from Bull, de Therap., torn. vi. p. 288. 

* Gross, System of Surg., 5th. ed., vol. i. p. 964. Med. Record (N. Y.), Dec. 22, 
1877. 

5 Malgaigne, from Bull, de la Soc. Anat., Juin, 1826. 

6 Ibid., from Archiv. de Med., Janv. 1827. 

7 Ibid., from Gaz. Med., 1842, p. 361. 

8 London Med.-Chir. Rev., vol. xvii , new series, p. 536, 1832. 



FRACTUKES AND DIASTASES OF THE STERNUM. 181 

sion, and in others, also, there is no evidence that the muscles attached 
to the sternum were put upon the stretch. The only remaining explana- 
tion is that in such cases the sternum has been broken by the violent 
shock, or contrecoup. I have myself seen one similar example. In 
December, 1877, John McLaughlin, set. 27, was admitted to my service, 
Bellevue Hospital, who had fallen from a height upon his back, causing 
a separation of the manubrium from the gladiolus. There was no sign 
of contusion over the point of separation, but crepitus was distinct. The 
fragments were easily replaced and maintained in position, so that when 
he left the hospital the line of separation could scarcely be felt. 

Dr. Hodgen has reported to me an example of fracture of the sternum 
caused by a crushing force applied to the back, and in which, we may 
see plainly, that muscular action was not concerned. A man, seated 
upon a wagon, was driving under a low bridge with his head very much 
bent down. The bridge caught his back, opposite the shoulders, and 
crushed him forwards, " separating the vertebrae in the dorsal region, 
and breaking the sternum about three inches below its upper end." 
This man recovered. 

Among the most authentic examples of separation of this bone from 
muscular action alone are those in which it occurred during labor. Mal- 
gaigne collected three of these cases, and to these the American trans- 
lator, Dr. Packard, added two more, most of which took place at or near 
the junction of the first and second pieces of the sternum. Dr. Borland 
has added one more example, which took place at a point near the fourth 
costal cartilage. 1 

Malgaigne relates also the case of a mountebank, who, leaning back 
to lift with his feet and hands a weight, felt suddenly a severe pain in 
the sternal region, and fell over with a fracture of this bone. 

Caseaux, in his Midwifery, says that Chaussier saw two such cases 
occurring in young women in their first labors (both of these are 
included in the cases recorded by Malgaigne) ; the separation having 
occurred when the head was thrown backwards as far as possible. Compte 
and Martin, 2 Luchette, and Posta 3 have reported similar examples. 

Mr. Ancelot has reported a case from gymnastic exercise. 4 

The mere act of violent coua-hino; has caused diastasis or fracture of 
the sternum. Mr. Howbridge, referring to the G-azette des Hopitavx 
for March, 1830, remarks, that the ribs and the sternum have been 
broken in this way ; but he acids, that in all probability they were weak- 
ened by partial absorption or atrophy. 5 

Lutz reports a case also, of a man set. 38, the subject of rheumatism 
and asthma, and who had also emphysema of a portion of one lung. 
During a violent fit of coughing he felt something give way on his chest. 
Severe pain followed, and some swelling. Lutz found the manubrium 

1 J. N. Borland, M.D., Boston Med. and Surg. Journ., April 20, 1875. 

2 Classical Diction. Med. and Surgery, xir. 70, Venice. Quoted by Borland, loc. 
fit. 

3 Bulletino delle Scienze Med. di Bologna, 1857. Quoted by Borland, loc. cit. 

4 Ancelot, from Lutz. 

5 Holmes's System of Surgery, 2d. ed., vol. ii. p. 37. 



182 FRACTURES AND DIASTASES OF THE STERNUM. 

separated from the gladiolus, the former being slightly displaced for- 
wards. He was much relieved of his distress by "stretching his neck 
and throwing his head backwards." Lutz directed him to make a 
deep inspiration, at the same time throwing back the head and shoulders. 
A compress was placed over the projection, and secured in place by a 
broad and firm band covering the entire chest. Union took place, but 
with a slight overlapping. 1 

Malgaigne says that Duverney was the first to recognize in certain of 
these accidents a veritable luxation ; and Malgaigne further affirms that 
he has collected in all ten cases which should be regarded as luxations. 
According to the plan which I have adopted of disregarding the dis- 
tinction between fractures, diastases, and dislocations of the sternum, 
for the reason chiefly that the exact diagnosis is in general impossible, 
and never of any practical value, these cases referred to by Mal- 
gaigne should be included in this enumeration of fractures and diastases. 

Boyer believed that the xiphoid cartilage was not susceptible of being 
permanently displaced backwards, except in aged persons, after it had 
become ossified, " for," he says, " though violently struck and driven 
backwards by a blow on what is vulgarly termed the pit of the stomach, 
yet it restores itself by its own elasticity." 2 

The following case, however, which has come under my own observa- 
tion, is conclusive as to the possibility of this accident : — 

A man, twenty-eight years old, fell forwards, striking the lower end 
of his sternum upon the top of a candlestick, breaking in the xiphoid 
cartilage. During two years following the accident he had frequent 
attacks of vomiting, which were excessively violent and distressing, the 
paroxysms occurring every five or six days. Both Dr. Green, of 
Albany, and Dr. White, of Cherry Valley, upon whom he called for 
relief, recommended excision of the cartilage, but the patient would 
not submit to the operation. Twelve years after the accident, in the 
year 1848, w T hile he was an inmate of the Buffalo Hospital of the 
Sisters of Charity, I examined his chest, and found the xiphoid carti- 
lage bent at right angles with the sternum, pointing directly toward the 
spine. He now suffered no inconvenience from it, except that it hurt 
him occasionally when he coughed. 3 

The direction of these fractures and diastases is generally transverse, 
or nearly so ; occasionally a slight obliquity is found in the direction of 
the thickness of the bone. In three Or four examples upon record, the 
direction of the separation was longitudinal. It is not so unfrequent, 
however, to find the bone comminuted. Compound fractures are exceed- 
ingly rare. 

When the line of separation is transverse, the lower fragment is 
generally displaced forwards, and sometimes it slightly overlaps, the 
upper fragment ; in other cases the direction of the displacement is the 
reverse. 

1 Paper read before the St. Louis Medical Society by F. J. Lutz, A.M., M.D. St. 
Louis Med. and Surg. Journ., July, 1877. 

2 Boyer on Diseases of Bones, p. 59. 

3 Buffalo Med. Journ., vol. xii. p. 282, Cases of Fractures of the Sternum. 



FRACTURES AND DIASTASES OF THE STERNUM. 18o 

I have seen a remarkable case of separation of the manubrium from 
the gladiolus, accompanied with a true fracture and other complications. 

Louis Wilson, set. 60, was admitted into the Long Island College 
Hospital, April 4, 1866, having just fallen through the hatchway of a 
vessel. He had a compound comminuted fracture of the right leg, a 
fracture of the four first ribs on each side at their necks, a dislocation 
of the sternum from the cartilages of both second ribs, a dislocation of 
the left third cartilage from its rib, a dislocation of the first from the 
second bone of the sternum, and a transverse fracture of the sternum 
three-quarters of an inch below the top of the gladiolus. The dislo- 
cation of the manubrium was complete, and it was thrust behind the 
upper end of the gladiolus, underlapping it half an inch. The trans- 
verse fracture three-quarters of an inch lower down was also complete, 
and the fragment thus separated was divided into two, namely, an 
anterior and a posterior fragment, by a transverse splitting ; the ante- 
rior moiety retaining its attachment to the periosteum below, and not 
being displaced, while the posterior moiety retained its attachment to 
the periosteum both above and below, and was pushed downwards by 
the descent of the manubrium. His mind was clear, but he had paralysis 
of the bladder, and was breathing with some embarrassment. I had no 
difficulty in diagnosticating the dislocation of the third cartilage, and of 
the manubrium. There was no swelling or discoloration on the front of 
the chest, but it was quite tender. His head was not thrown forwards. 
He complained of some soreness on the back of his head. His general 
condition was such that I did not attempt reduction. The following 
day he expectorated blood, and on the third clay he died. The autopsy 
revealed some effusions of blood underneath the pleura, but no lesions 
of the heart or lungs. The evidence is in this case conclusive that he 
struck upon his back and head, in fact, that it was a fracture from 
counter-stroke, by which the head, neck, and three or four upper ver- 
tebrae were bent forwards with great force, thus doubling forwards the 
top of the sternum. 

Dr. Robert Watts, Jr., of this city, has reported a very similar case, 
in which death occurred on the same day. The fragments of the sternum 
were not displaced, but the ribs had suffered similar lesions. 1 

Diagnosis. — In a few cases the patients have felt the bone break at 
the moment of the accident. When displacement exists, it may gene- 
rally be easily recognized, and the lower fragment will often be seen 
to move forwards and backwards at each inspiration and expiration. 
Crepitus may also be detected in some of these examples. To deter- 
mine its existence, the hand should be placed over the supposed seat of 
fracture, while the patient is directed to make forced inspirations and 
expirations, or the ear may be applied directly to the chest. 

Emphysema has, also, occasionally been noticed, indicating usually 
that the lungs have been penetrated by the broken fragments. 

The frequent occurrence of congenital malformations of the sternum 
should warn us to exercise great care in our examinations, lest we mis- 
take these natural irregularities for fractures. The point of junction of 

1 Watts, Am. Med. Times, vol. iii. p. 55. 



184 FEACTUEES AND DIASTASES OF THE STERNUM. 

the first and second portions has also occasionally been observed to be 
somewhat projected forwards in cases of chronic asthma and emphysema 
of the lungs. Bransby Cooper mentions a remarkable instance of mal- 
formation of the xiphoid cartilage which he at first suspected to be a 
fracture. It was so much curved backwards that, as Mr. Cooper thinks, 
its pressure upon the stomach produced a constant disposition to vomit 
whenever he had taken a full meal, or had taken a draught of water. 1 

Prognosis. — In simple fracture or diastasis of this bone, uncompli- 
cated with lesions of the subjacent viscera, and especially when the 
separation is the result of muscular action or of a counter-stroke, no 
serious consequences are to be apprehended. The bone unites promptly 
by osseous or fibrous tissue, even where it is found impossible to bring 
its edges into apposition. Indeed, generally, where the fragments have 
been once completely displaced, although it is not difficult to replace 
them momentarily, a redisplacement soon occurs, and they are found 
finally to have united by overlapping ; but no evil consequences usually 
result from this malposition. In nearly all of the cases reported in 
which palpitations, difficult breathing, etc., have been charged to the 
persistence of the displacement, the injuries were of such a character as 
to furnish for these unfortunate results other and much more adequate 
explanations. In one instance only, already mentioned, serious incon- 
veniences followed from a displacement of the cartilage backwards. 

In other cases, however, where the fracture is the result of a direct 
blow, the prognosis is often very grave ; a conclusion to which one would 
naturally arrive from the fact already stated, that the fracture of the 
sternum thus produced, in itself implies the application of great force. 

An abscess occurring in the anterior mediastinum, and caries or 
necrosis of the bone, are among the most common results of a blow 
delivered directly upon the sternum ; complications which generally end 
sooner or later in death. Blood may be also extensively effused into the 
anterior mediastinum. 

A remarkable case of recovery after gunshot injury of the sternum is 
reported by the U. S. Medical Bureau: — 

Private C. Betts, 26th N. J. Vols., set. 22, was struck by a three- 
ounce grapeshot, May 3, 1863, in the charge upon the heights at Fred- 
ericksburg, Va. The ball comminuted the sternum, opposite the third 
rib on the left side, penetrating the costal pleura. The patient removed 
the ball from the wound himself. On the following day he was admitted 
to the hospital of the second division of the sixth corps. Through the 
wound the arch of the aorta was distinctly visible, and its pulsations 
could be counted. The left lung was collapsed ; when sitting up, there 
was but slight dyspnoea. Several fragments of the sternum were re- 
moved. The wound soon began to heal, and he made a complete 
recovery. 2 

Where emphysema is present, we may anticipate inflammation of the 
pleura and of the lungs. 

In several instances, where death has occurred speedily after the in- 

1 B. Cooper, Prino. and Pract. of Surg., p. 359. 

2 Circular No. 6, Washington, D. C, Nov. 1, 1865, p. 23. 



FRACTURES AND DIASTASES OF THE STERNUM. 185 

jury, the heart has been found penetrated and torn by the fragments. 
Sanson and Dupuytren have each reported one example of this kind. 
Duverney has mentioned two, and Samuel Cooper says there is a speci- 
men in the museum of the University College, exhibiting a laceration of 
the right ventricle of the heart by a portion of fractured sternum. Wat- 
son mentions a case in which the pericardium was torn but the heart was 
only contused. 1 

Treatment. — When the fragments are not displaced, the only indica- 
tions of treatment are to immobilize the chest, and to allay the inflam- 
mation, pain, etc., consequent upon the injury to the viscera of the chest. 
The first of these indications is accomplished, at least in some degree, 
by inclosing the body, from the armpits down to the margin of the float- 
ing ribs, with a broad cotton or flannel band. A single band, neatly 
and snugly secured, and made fast with pins, is preferable to, because it 
is more easily applied than, the roller which surgeons have generally 
employed ; it is also much less liable to become disarranged. It should 
be pinned while the patient is making a full expiration. To prevent its 
sliding down, two strips of bandage should be attached to its upper mar- 
gin, and crossed over the shoulders in the form of suspenders. 

Generally the patients prefer the half-sitting posture, with the head 
and shoulders thrown a little backwards ; and this is the position which 
will be most likely to maintain the fragments in place, and also to secure 
immobility to the external thoracic muscles, while it leaves the diaphragm 
and the abdominal muscles free to act. 

The second indication may demand the use of the lancet ; but more 
often it will be found necessary to allay the pain and disposition to cough 
by the use of opium. 

If, however, the fragments are displaced, it is proper first to attempt 
their reduction ; which, as we have already intimated, is generally more 
easy of accomplishment than is the maintenance of them in place until a 
cure is effected. 

The fragments may sometimes be made to resume their natural position 
by a single full inspiration ; but then they usually fall back during expi- 
ration ; or they may be reduced by straightening the spine forcibly, and 
at the same time drawing the shoulders back. 

Verduc and Petit proposed, in those cases in which it was found impos- 
sible to reduce the fragments by these simple means, to cut down and 
lift the depressed bone. Nelaton suggests the use of a blunt crotchet 
introduced through a narrow incision ; and Malgaigne has thought of 
another plan, which is, to penetrate the skin with a punch, and directing 
it to the broken margin, to push the fragment into its place, but which 
he does not himself regard as a suggestion of much value, since the bone 
is too soft to afford the necessary resistance ; and, moreover, this, in 
common with all of the other similar methods, is liable, in some degree, 
to the objection that it may increase the tendency to caries and suppu- 
ration, already imminent. If reduced, the fragments will probably im- 
mediately again become displaced ; and more than all, it still remains to 

1 New York Journ. of Med., vol. iii. p. 351. 
13 



186 FRACTURES OF THE RIBS AND THEIR CARTILAGES. 

be proven conclusively that the mere riding of the fragments is in itself 
ever a cause of subsequent suffering, or even of inconvenience. 

When an abscess has formed in the anterior mediastinum, surgeons 
have occasionally recommended the use of the trephine. Gibson has 
twice operated in this manner at the Philadelphia Hospital, but in each 
case the caries continued to extend, and the patient died ; an experience 
which has inclined him latterly to discountenance the operation. 1 

There are other considerations mentioned by Lonsdale, which ought 
to decide us never to use the trephine in these cases. " For the symp- 
toms denoting the presence of the abscess, when completely confined to 
the under surface of the bone, will be very uncertain; and when the 
matter collects in large quantities, it will show itself at the margin of the 
sternum, between the ribs, when it can be let out by making a puncture 
with the point of a lancet, without the necessity of removing a portion of 
the bone.'" 2 Ashhurst, referring to the same point, remarks : "The 
fact that the mediastinal space can be cut into without injury to the 
pleura is shown by many cases, among others by one which came under 
my own observation." 3 



CHAPTEE XVIII. 

FRACTURES OF THE RIBS AND THEIR CARTILAGES. 

§ 1. Fractures of the Ribs. 

Fractures of the ribs, observed more often than fractures of the 
sternum, are rare as compared with fractures of other long bones. 

In my records, not including fractures from gunshot injuries, only 
thirty-two patients are reported as having had broken ribs ; but as in 
several of the cases two or more ribs were broken at the same time, the 
total number of fractures is about sixty -five. If, however, I had always 
accepted the diagnosis made by other surgeons, the number would have 
been much greater, since I have been repeatedly assured that the ribs 
were broken when, upon the most careful examination, no evidence, be- 
yond the existence of a severe pain and of difficult respiration, has been 
presented to me. 

Etiology. — The force requisite to break the ribs is scarcely less than 
what is requisite to break the sternum ; and in childhood and infancy it 
is sometimes almost impossible to break them, so that children and even 
adults are often crushed and killed outright, where, although the pres- 
sure has been directly upon the thorax, the ribs have resumed their posi- 
tions, and have been found not to be broken. 1 have met with several 
examples of this kind. 

1 Gibson, Institutes and Practice of Surgery, vol. i. p. 269. 

2 Lonsdale, Practical Treatise on Fractures, London, 1838, p. 242. 
a Ashhurst, Am. Journ. Med. Sci., Jan. and Oct. 1862. 



! 



FRACTURES OF THE RIBS. 187 

In old age, the cartilages ossify and the ribs themselves suffer a gradual 
atrophy, which renders them much more liable to break. 

The most common causes are direct blows, of very great force, in 
consequence of which sometimes the fragments are not only broken, but 
more or less forced inwards ; occasionally they are the result of counter- 
strokes, and then the fragments, if they deviate at all from their natural 
position, are salient outwards ; a species of fracture which I have not 
met with so often. 

Malgaigne has collected eight examples of fractures of the ribs pro- 
duced by muscular action, by the beating of the heart, etc., all of which 
occurred upon the left side. It is believed, however, that in all of these 
cases the ribs had previously become atrophied, and perhaps undergone 
other changes in their structure, rendering them liable to fracture from 
the action of trivial causes. 

Pathology, Seat, etc. — The fourth, fifth, sixth, and seventh ribs are 
most liable to be broken ; the upper ribs, and especially the first rib, 
being so well protected in various ways as to greatly diminish their lia- 
bility, while the loose and floating condition of the last two ribs gives 
them an almost complete exemption. 

Malgaigne has noticed, also, contrary to the general opinion of sur- 
geons, that the ribs are most often broken in their anterior thirds, whether 
the cause has been a direct or a counter blow. My own observations 
confirm this statement. 

The direction of the fracture is generally transverse or slightly ob- 
lique ; sometimes it is quite oblique. It is often compound ; and in a 
few instances I have found it comminuted or multiple. Where the frac- 
ture is compound, it is rendered so generally by the fragments having 
penetrated the lungs, and not by a tegumentary wound. 

Displacement cannot occur in the direction of the axis of the bone 
unless several ribs are broken at the same time. The fragments are 
therefore either not at all displaced, or they fall inwards toward the 
cavity of the chest, or outwards, or very slightly downwards, in the di- 
rection of the intercostal spaces. Sometimes the rib moves a little upon 
its own axis. 

Prognosis. — Death occurs sooner or later in a pretty large minority 
of the cases in which the ribs have been broken ; yet not often as a 
direct consequence of the fracture, but only as a result of the injury in- 
flicted upon the viscera of the chest, or of other injuries received at the 
same moment. The violent compression of the heart and lungs has fre- 
quently produced death, and sometimes, as I have more than once seen, 
almost immediately ; or the patients have succumbed at a later period to 
acute pneumonitis, or pleuritis. 

Lonsdale saw a case in which, the body of a man having been traversed 
by the wheel of a wagon, eight ribs were broken, and, death having fol- 
lowed almost immediate^, the autopsy disclosed a rent in the left auricle 
of the heart, produced by one of the broken ribs. 1 South says there is 
such a specimen at St. Thomas's Hospital. 2 

1 Lonsdale on Fractures, p. 258. 

2 Chelius's Surgery, by South, vol. i. p. 599. 



188 FRACTURES OF THE RIBS AND THEIR CARTILAGES. 



Dupuytren reports a similar case. The same surgeon has also seen 
several deaths produced by the emphysema, independent of the fracture, 
two of which are particularly described in his Clinical Lectures. 1 
Amesbury has seen a case of death from rupture of the intercostal 
artery, where there was no injury of the lungs. 2 

In several instances observed by me, patients have suffered from 
pains in the side, occasionally from cough, etc., after the lapse of two 
or more years, and I suspect it is no uncommon thing for these injuries 
to entail some such permanent disability, but which is a consequence 
rather of the injury to the viscera of the chest, than of any condition of 
the broken ribs themselves. 

In general, simple fractures of the ribs unite in from twenty -five to 
thirty days. Malgaigne has seen one case of non-union; Huguier met 
with another upon the cadaver, in which a complete false joint existed, 
furnished with a capsule and lined with synovial membrane ; 3 Eve, of 
Nashville, Tenn., saw a case of non-union, occasioned, probably, by a 
caries or necrosis of the bone, since it was accompanied with a discharge 
of matter, and in which a removal of the ends of the fragments resulted 
promptly in a cure of the sinus ; 4 and Samuel Cooper says there is a 
specimen in the Museum of the University College, of a fracture of six 
ribs where the fragments are only connected by a fibrous or ligamentous 
tissue. 5 

The union generally occurs with only a slight degree of displace- 
ment. 

After the union is completed, even where there is no displacement, a 
certain amount of ensheathing callus may generally be felt at the point 
of fracture. Of five cases which I have carefully examined after re- 
covery, in only one in- 
Fig. 43. stance was I unable to 

detect any irregularity at 
this point. I have in my 
cabinet nine specimens of 
fractured ribs, in four of 
which the ensheathing 
callus is completely form- 
ed, but the fragments are 
in perfect apposition : in 
one, apposition is pre- 
served, but there is no 
ensheathing callus; and 
the remaining four, all 
occurring in the same person, are united with displacement, but without 
a proper ensheathing callus. 

In some specimens I have observed sharp spicula, in others broader 
sheets of bone extending along the course of the intercostal muscles 
from one rib to the other, forming a species of anchylosis between their 
adjacent margins. 




Fractured ribs joined to each other by osseous matter. 
(From Dr. Gross's cabinet.) 



1 Dupuytren, op. cit. p. 79. 
3 Malgaigne, op. cit. p. 435. 
5 S. Cooper's Surg,, vol. ii. p. 321. 



2 Amesbury on Fractures, vol. ii. 612. 
4 Eve, N. Y. Journ. Med., vol. xv. p. 136. 



FEACTUEES OF THE RIBS. 189 

Symptomatology. — Acute pain, referred especially to the point of 
fracture, sometimes producing great embarrassment in the respiration, 
and crepitus, are the most common indications of a fracture. The pain 
and embarrassed respiration are, however, far from being diagnostic, 
since they are often present in an equal degree when the walls of the 
chest have only been severely contused. 

The crepitus, also, is often difficult to detect, owing to the thickness 
of the muscular coverings, or to the amount of fat upon the body, or to 
the fracture having occurred perhaps directly underneath the mammae 
in the female. In three instances, where the presence of emphysema 
rendered the existence of a fracture quite certain, I have been unable 
immediately after the accident to discover crepitus. 

The crepitus may be discovered sometimes by pressing gently upon 
the seat of fracture, or by applying the ear or the stethoscope over this 
point while the patient attempts a full inspiration, or coughs ; or we 
may press upon the front of the chest with one hand, while the fingers 
of the other hand rest upon the fracture. 

Occasionally the patient has felt the bone break, and very often he 
feels or hears the crepitus after it is broken, and will himself indicate 
very clearly the point of fracture. 

At the same time that we detect crepitus we are able also to discover 
motion in the fragments, but I have once or twice discovered preter- 
natural mobility without crepitus. 

Emphysema, which is almost certainly indicative of a fracture, is 
present in a pretty large proportion of cases. It has been observed by 
me in 13 out of 32 cases; generally it did not extend over more than 
two or three square feet of surface ; but in two cases it finally extended 
over nearly the whole body. It is remarkable, however, that in only 
four of these thirteen cases did the patients expectorate blood, and then 
in a very small quantity, and usually not until the second or third day. 

Desault observes that emphysema rarely succeeds to fractures of the 
ribs ; an observation which, as will be seen, my experience does not 
confirm. 

Treatment. — In simple fractures, where there is no displacement, or 
where the displacement is only moderate, the chest may be inclosed 
with a broad belt or band, as we have already directed in case of frac- 
ture of the sternum; provided always that it is not found to increase 
instead of diminishing the patient's sufferings. Some patients cannot 
tolerate this confinement at all; while, with a majority, although it is 
at first uncomfortable and oppressive, after an hour or two it affords 
great relief from the distressing pain, and they will not consent to have 
it removed even for a moment. In nearly all cases of comminuted frac- 
ture it is inadmissible, on account of its tendency to force the pieces 
inwards. 

Hannay, of England, has suggested the use of adhesive strips as a 
substitute for the cotton or flannel band ; the several successive pieces 
being imbricated upon each other until the whole chest is covered. 1 

1 American Journ. Med. Sci., vol. xxxix. p. 198. From Lond. Med. Graz., Nov. 
1845. 



190 FRACTURES OF THE RIBS AND TEIEIR CARTILAGES. 

The same objection holds to this mode of dressing as to a similar mode 
of dressing a broken clavicle, which has been recently recommended. 
It will certainly become loosened after a few hours, by the slight but 
uninterrupted play of the ribs, and it is not as comfortable as a woollen 
or cotton band. 

The forearm ought also to be brought across the chest at a right angle 
with the arm, and secured in this position with a moderately tight band- 
age or sling, so as to prevent any motion in the pectoral muscles. 

As to position, the patient generally prefers to sit up, or he chooses 
a position only partly reclining upon his back ; but there is no positive 
rule to be observed in this matter, except that such a position shall be 
chosen as shall prove most comfortable to the patient. 

If the fragments are salient outwards, the fracture having been pro- 
duced by a counter-stroke, they may be reduced by pressing gently upon 
them from without. If, on the contrary, the fragments are salient in- 
wards, they will be found, in a great majority of cases, to have resumed 
their positions spontaneously or through the natural actions of respira- 
tion ; but if they have not, it will be exceedingly difficult to restore 
them. Possibly it may be accomplished by pressing forcibly upon the 
front of the chest, or upon the anterior extremity of the broken rib ; 
yet if the fragments are comminuted, and the ends are much driven in, 
this method will avail little or nothing. In such cases several surgeons 
have recommended that we should cut down to the bone and elevate the 
fragments, but Rossi alone claims to have actually put the suggestion 
into practice. 

No doubt, if the necessity was urgent, this method might be success- 
fully adopted; or, instead of cutting down to the broken rib, we might 
even seize the fragment with a hook, as suggested by Malgaigne, or, 
what in some cases might be even more convenient, with a pair of forceps 
constructed with long teeth, obliquely set upon a firm shaft. Yet the 
exigency which will demand a resort to any of these measures will be 
exceedingly rare. In gunshot fractures, which are nearly all compound 
and comminuted, the loosened or detached fragments should be at once 
removed. 

In no case do I attach any value or importance to the advice given 
by Petit, that we shall place a compress upon the front of the chest, un- 
derneath the bandage, in order to reduce the fragments, or to retain 
them in place after reduction. Lisfranc, who advocated this method, 
claimed that its advantage consisted in the increased length which was 
thus given to the antero-posterior diameter of the chest, and the conse- 
quent accumulation of pressure from the encircling band, in this direc- 
tion. 1 The mechanical law is no doubt correctly stated, but its value in 
practice is too inconsiderable to deserve consideration. 

The emphysema generally demands no special attention, since it is 
usually too limited to occasion inconvenience ; and when more extensive, 
it generally disappears spontaneously after a few days, or a few weeks 
at most. The advice given by some surgeons, that we ought in these 
cases to cut down to the pleural cavity so as to allow the air to escape 

1 Ranking's Abstract, vol. ii. p. 204, from Gaz. des Hopitaux, July 8, 1845. 



FRACTURES OF THE CARTILAGES OF THE RIBS. 191 

freely through the incision, seems thus far to have rested its reputation 
upon a more than doubtful theory rather than upon any testimony of ex- 
perience. Abernethy alone, so far as I know, has actually made the 
experiment, and his patient died. 

Dupuytren, in the two cases already alluded to, bled the patients and 
applied resolvent liquids, with rollers ; he also made incisions with the 
lancet at various points of the body, more or less remote from the seat 
of fracture, a practice, however, in which he confesses he has no confi- 
dence whatever. These patients both died. 

Dr. Stedman, of the Massachusetts General Hospital, has reported the 
case of a man aged sixty-nine, of intemperate habits, who, in addition 
to a fracture of one of his ribs, had also a dislocation of the outer end 
of the clavicle. The emphysema commenced immediately, and reached 
its acme on the twenty-second day. At this time it had extended over 
his whole body ; his eyes were closed, and he breathed with great diffi- 
culty ; but on the forty-fifth day the emphysema had entirely disappeared, 
and he was dismissed cured. The treatment consisted chiefly in the free 
internal use of stimulants, and in the application of bandages ; but the 
bandages soon became disarranged, and after a few days they were en- 
tirely laid aside. 1 

In the case of one of my own patients, where the emphysema was 
almost equally extensive, the patient recovered after a few weeks, under 
the use of a simple diet, and without any special medication whatever. 
The second case of extensive emphysema, observed by me, was as fol- 
lows : A man was crushed, under a bank of earth, Sept. 19, 1860. 
Two hours after the accident I found him greatly prostrated. Six ribs 
were broken on the left side near the spine, and one on the right side. 
In coughing he expectorated some blood. There was emphysema of the 
face and over the front of the chest. He died at 9 P. M., having sur- 
vived the accident only about six hours. The autopsy showed the left 
lung penetrated at two points, and collapsed ; about six ounces of blood 
in the left pleural cavity; lower lobe of right lung crushed and disor- 
ganized, but the remainder of the lung not collapsed. The features of the 
face were almost obliterated by the emphysema, which had also invaded 
the mediastinal space, and extended over the body as low as the knees. 

§ 2. Fractures of the Cartilages of the Ribs. 

Boyer was incorrect when the said that the cartilages of the ribs could 
not be broken until they were ossified. They are often broken when 
there is no ossification, at the same time that the ribs themselves are 
broken. Sometimes they are broken alone. Not unfrequently, also, 
the separation takes place at the precise point of junction between the 
cartilage and the bone. 

Pyper relates a case in which the sternum was broken in a man aged 
twenty-five years, and also the cartilages of the sixth, seventh, and 
eighth ribs of the right side, as was proven by the autopsy, yet the 
cartilages were not ossified. The vena cava ascendens was also rup- 

1 Boston Med. and Surg. Journ., vol. lii. p. 316. 



192 FKACTURES OF THE RIBS AND THEIR CARTILAGES. 

tured by the force of the compression. 1 The reader is referred also to 
my own and Dr. Watts' s cases reported in the chapter on Fractures of 
the Sternum. Since the date of the report of these cases I have met 
with several examples of fracture of the cartilages. 

Etiology. — The causes are the same as those which produce fractures 
of the ribs, yet it is generally understood that it will require greater 
force, and that consequently the injury done to the viscera of the thorax 
will be more complicated and intense. 

In the reports of the Massachusetts General Hospital an account is 
given of the case of a man aged thirty, who was crushed by the fall of 
a heavy weight upon his body, and who died after about sixty hours. 
An examination after death revealed a fracture of the cartilages of the 
third and fourth ribs, with a laceration of the intercostal muscles to 
such an extent that a hernia of the lungs had occurred at this point. 
This hernia had been discovered and recognized by Dr. Warren soon 
after the accident occurred ; the protrusion being at that time as large 
as the clenched fist, and regularly rising and falling with each move- 
ment of respiration. It was accompanied, also, with a moderate emphy- 
sema. 

Pathology. — The fracture is clean and vertical, or transverse ; never 
irregular or oblique. The direction of the displacement varies as in 
fractures of the ribs, but the anterior or sternal fragment is generally 
found in front of the posterior or spinal. 

Union takes place in these fractures, not through the medium of 
cartilage, but of bone. Sometimes the new bone is deposited only 
between the ends of the fragments, in the form of a thin plate; at 
other times it is formed around the fragments as well as between them. 
The latter of these two processes has been most frequently observed. 
The ensheathing callus appears to be supplied by the perichondrium, 
while the experiments of Dr. Redfern render it probable that the in- 
termediate callus may result from a conversion or transformation of 
the adjacent cartilaginous surfaces. Paget remarks, also, that the ossi- 
fication extends to the parts of the cartilage immediately adjacent to the 
fracture. 

I have seen one example, in the person of Hiram Leech, get. 38, 
which, after the expiration of more than one year, had not united. 
The fracture had occurred in the united cartilages of the ninth and 
tenth ribs. The posterior fragment overlapped the anterior, and they 
played freely upon each other at each act of inspiration and expiration. 

I do not know that any observations have been made upon the repair 
of these cartilages in very early life, and it is possible that the process 
may differ from this, which has been described as it has been observed 
in the adult. 

Treatment. — The treatment need not differ from that already recom- 
mended for fractured ribs. 

1 Banking's Abstract, vol. i. p. 147, from the Lancet, Oct. 1844. 



FKACTURES OF THE CLAVICLE. 193 



CHAPTEE XIX. 

FRACTURES OF THE CLAVICLE. 

For the sake of convenience, I shall divide fractures of the clavicle 
into those occurring through the inner, middle, and outer thirds. By 
the "outer third" is meant all that portion of the clavicle included 
between its scapular extremity and the internal margin of the conoid 
ligament. The remaining portion is intended to be divided equally into 
two separate halves. The peculiarities of these several portions, in 
respect to anatomical relations, liability to fracture, results, etc., will 
explain the propriety of the divisions. 

Causes. — If we except gunshot fractures, the clavicle is broken, in a 
large majority of cases, by a counter-stroke, such as a fall, or a blow 
upon the extremity of the shoulder. 

Occasionally it is broken by a direct stroke, as when a blow aimed at 
the head is received upon the shoulder ; it is broken sometimes by the 
recoil of an overloaded gun, especially when the person lies upon the 
ground, with the butt of the gun resting against the clavicle. 

Gibson has seen a case in which it was broken in a child at birth, by 
an ignorant midwife pulling at the arm, 1 and Dr. Atkinson has reported 
an example of intra-uterine fracture of the clavicle. 2 

Gurlt has collected seven cases of intra-uterine fracture of the clavicle 
caused by external violence. 3 

I have once seen the clavicle broken by muscular action alone. A 
large, well-built, and healthy man, aged thirty-seven, standing upon 
the ground, attempted to secure the braces of his carriage-top with his 
right arm, when he felt a sudden snap, as if something about his shoulder 
had given way. He did not, however, suspect the nature of the injury, 
and did not consult any surgeon until eight days after, at which time 
I found the right clavicle broken near its centre, but rather nearer the 
sternal than the scapular extremity. The fragments were but slightly, 
if at all, displaced, but motion and crepitus at the point of fracture were 
distinct. A node-like swelling was also present, indicating the existence 
of a considerable amount of ensheathing callus. He had been unable to 
raise the arm to a right angle with the body since it was broken, but he 
had suffered no other inconvenience from it. 

A similar case is reported in the number for January, 1843, of the 
American Journal of Medical Sciences, copied from the Revista Medica. 
The subject of this case was a colonel of cavalry, about sixty years of 
age. In mounting his horse, he experienced a sensation as if something 

1 Gibson, Principles of Surg., sixth ed., vol. i. p. 272. 

2 Atkinson, Bost. Med. and Surg. Journ., July 26, 1860. 

3 Gurlt, Holmes's Surgery, ed. of 1870, vol. ii. p. 765. 



194 FRACTURES OF THE CLAVICLE. 

had broken, followed by acute pain in his left shoulder, and, on exam- 
ination, it was found that the clavicle was fractured in the middle. The 
health of this gentleman had been impaired, it is further stated, by re- 
peated attacks of syphilis. 

W. E. Whitehead, U. S. N., has reported the case of a healthy and 
muscular man, twenty-eight years old, who broke his left clavicle at the 
junction of the outer and middle thirds, while attempting to raise himself 
to a platform eight feet high. The fracture was transverse, and unac- 
companied with displacement. 1 

Malgaigne has recorded three other examples of fracture of this bone 
from muscular action ; and Parker saw a case which was produced by 
striking at a dog with a whip. The bone, in the latter case, had been 
previously somewhat diseased, yet it united favorably. 2 

Of these seven cases, five occurred on the right side, and always near 
the middle of the bone, if we except one case reported by Malgaigne, in 
which the point of fracture is not mentioned. In neither case did the 
fragments become displaced, only as they were found, in some of the 
examples, inclined slightly forwards. 

Gurlt has collected twenty cases of fracture from this cause. 3 

Dr. Pooley reports an example of fracture of the clavicle in a child, 
supposed to have been due to muscular action, and which was the result 
of a fall upon the back. 4 It does not appear to me absolutely certain 
that the manner of the fall has been determined, and that it can be fairly 
set down as due directly to muscular action. 

Pathology. — It has already been observed, in speaking of partial 
fractures, that this bone suffers an incomplete fracture more often than 
any other, and that in such cases the lesion occurs generally in the 
middle third, or rather to the sternal side of the centre, and in a direc- 
tion nearly or quite transverse. They are not usually accompanied with 
much displacement ; but if a displacement exists, it is a slight forward 
inclination of the fragments. 

Fractures which are complete occur mostly after the bones have 
become firm and unyielding. They are also generally oblique, seldom 
comminuted, still more rarely compound. The point of the clavicle at 
which a complete fracture usually occurs is at or near the outer end of 
the middle third, and a little to the sternal side of the coraco-clavicular 
ligaments, near where the trapezius and deltoid cease their attachments. 
It might be more exact to say that the fracture extends from this point 
downwards and inwards, toward the sternum, embracing one inch or less 
of its entire length. In some cases the obliquity is greater, and the 
amount of bone involved is much more considerable. 

Why the bone should break more frequently at this point, especially 
in the adult and in the male, it is not difficult to understand. It is 

1 Whitehead, Pacific Med. and Surg. Journ., 1871. 

2 Parker, N. Y. Journ. Med., July, 1852. 

3 Gurlt, Holmes's Surgery, ed. of 1870, vol. ii. p. 765. See also paper by M. Deleus 
on Fractures of the Clavicle from Muscular Action, in Archives Generales, March, 
1875. 

4 J. H. Pooley, Prof. Surg. Starling Med. Coll., Columbus, Ohio. A Clinical Lec- 
ture, 1877. 



FRACTURES OF THE CLAVICLE. 



195 



Fig. 44. 



smaller here than elsewhere, and less supported by muscular and liga- 
mentous attachments. At this point, also, the axis of the bone begins 
pretty abruptly to curve forwards, and more abruptly in the adult and 
male than in "the child and female. When, therefore, the clavicle is 
broken, as it usually is, by a counter-stroke, the force of the blow, 
conveyed from the shoulder through the outer portion of the bone, is 
suddenly arrested, and expends itself upon the point where the direction 
of the axis is changed. 

In a record of one hundred and fifty-seven fractures, including partial 
and comminuted, and not including gunshot fractures, one hundred and 
twenty-seven have occurred through 
the middle third ; and, with the ex- 
ception of the partial fractures, the 
fracture has in nearly all of the cases 
taken place near the outer end of this 
third. Four have occurred through 
the inner third, three of which were 
within one inch of the sternum ; and 
seventeen through the outer third. 

A more practical analysis can be 
based, however, upon the point of 
fracture with reference to its cause ; 
and I have never, but once, seen a 
complete fracture of this bone, in the 
adult, produced clearly by a counter- 
stroke, which was not near the outer 
end of the middle third. 

When the fracture is at this point, 
or in any portion of the middle third, 
the direction of the displacement is 
almost uniformly the same. The sternal 
fragment is slightly lifted by the action of the clavicular portion of the 
sterno-cleido-mastoid muscle, notwithstanding the resistance of the rhom- 
boid ligament, the pectoralis major and the subclavius muscles. On the 
other hand, the acromial fragment is dragged downwards by the weight 
of the arm, aided by the conjoined action of a portion of the pectoralis 
major and the latissimus dorsi, feebly resisted by the trapezius and 
other muscles from above ; by the action of the same muscles, aided by 
the pectoralis minor, and perhaps by some portion of the subclavius, it 
is drawn toward the body, diminishing thereby the axillary space : 
while by the preponderating strength of the pectoralis major and minor, 
the acromial end of the fragment, with the shoulder, is drawn forwards ; 
the sternal end of the same fragment being rather displaced backwards, 
and at the same time resting at a point somewhat elevated above the 
acromial end. 

Desault has recorded one example of an overlapping by the eleva- 
tion of the acromial fragment over the sternal ;* and Bichat remarks 
that Hippocrates speaks of the phenomenon as a thing which was 




Complete oblique fracture of clavicle. 



1 Desault on Frac, op cit., p. 16. 



196 FRACTUEES OF THE CLAVICLE. 

familiar to him. Syme has mentioned a case of this kind which he 
had seen. 1 Gu^retin, Malgaigne, 2 and Stephen Smith have each re- 
ported an example. 3 In Stephen Smith's case the fracture occurred in 
a man thirty-eight years old. The bone was broken through the outer 
third, and transversely. He was treated at the Bellevue Hospital, but 
the overlapping, to the extent of one inch, remained after the cure was 
completed. 

Margaret O'Donnell, set. 40, was admitted to the Charity Hospital, 
Blackwell's Island, June 1, 1868, with a single fracture of the clavicle, 
near its middle, caused two weeks before, by a fall on the shoulder. 
The sternal fragment was lying beneath the acromial, and in this position 
it finally united. 

In nearly all cases of oblique fractures occurring through the middle 
third there follows immediately an overlapping, varying from one-quarter 
of an inch to an inch, and sometimes, though very rarely, exceeding 
this ; the average shortening being about half an inch. There is a speci- 
men in the Dupuytren Museum, in which the shortening equals one-third 
of its entire length. 

Transverse fractures, wherever they may occur, whether in children 
or adults, are seldom found displaced, at least in the direction of the 
axis of the bone, as the following examples will illustrate, and they 
unite usually without shortening or deformity : — 

An old lady, aged eighty years, fell down a flight of stairs, breaking 
the right clavicle transversely, about one inch from the sternum. I saw 
her, with Dr. Trowbridge, on the day following the accident. Motion 
and crepitus were distinct, but there was scarcely any displacement. No 
dressings were applied, but she was directed to keep quiet in bed, and 
upon her back. In the usual time the fragments had united, without 
deformity. 

A man, about forty years old, fell backwards from a wagon, breaking 
the collar-bone near the middle. The fragments were movable but not 
displaced. He was treated successfully and without any resulting de- 
formity, by simple confinement in the recumbent posture during a few 
days, and after this by suspending the arm in a sling, while he was per- 
mitted to walk about. 

A young man, aged twenty-six, fell while wrestling and broke the 
clavicle at the outer end of the middle third. There was some dis- 
placement at first, but the fragments, being reduced, were found to sup- 
port themselves. A cross, secured with straps, was applied to the back, 
and on the twenty-eighth day the union was complete, and without 
deformity. 

A child, aged three years, fell about six feet, striking upon his shoulder. 
He was sent to me on the same day, by Dr. G. Burwell. I found the 
left clavicle broken oif completely, about one inch from its scapular end. 
Crepitus and motion were distinct, but the fragments were not displaced. 
The arm was placed in a sling, and on the seventh day both motion and 
crepitus had ceased. The cure was accomplished without any degree of 
displacement. 

1 Amer. Journ. Med. Sci., vol. xvii. p. 251. 2 Malgaigne, p. 461. 

8 N. Y. Journ. of Med,, May, 1857. 






FRACTURES OF THE CLAVICLE. 197 

The example of a fracture from muscular action, already mentioned as 
having been seen by me, was also probably transverse, and union has 
occurred without treatment and without displacement. 

Stephen Smith, of New York, has met with two examples of trans- 
verse fractures without displacement, in a hospital record of eleven cases. 
Bichat says Desault has frequently observed the same, it having been 
seen three times at Hotel Dieu, in the course of the year 1787. * De- 
sault thinks, also, that sometimes the fracture, taking place obliquely 
upwards and inwards, the usual form of displacement is prevented, and 
apposition is preserved. In nearly all of the examples of partial trans- 
verse fractures, occurring in children, seen by me, there has been no lon- 
gitudinal displacement. 

If the fracture is near the sternum, and within the fibres of the costo- 
clavicular ligaments, as in the case of the old lady just cited, the dis- 
placement is inconsiderable. I have seen one other similar case, in an 
adult also. Lonsdale mentions a case, in a child three years old, which 
came under his observation in Middlesex Hospital, 2 which he regarded as 
a separation of the epiphysis, the point of fracture being half an inch 
from the sternum; but the only epiphysis in connection with this bone, 
is an exceedingly thin plate at the sternal end, which does not begin to 
ossify until about the eighteenth year of life. Neither the age of the 
patient, nor the point of separation, would justify an opinion that this 
was an epiphyseal separation. Malgaigne mentions two other examples, 
in one of which the fracture was so near the sternum that it was difficult 
to say whether it was not a partial dislocation. The displacement was 
only trivial. 3 But the only two specimens contained in the Dupuytren 
Museum offer a considerable displacement, and in both the external frag- 
ment is thrown downwards and forwards. 

March 22, 1865, I presented to the New York Pathological Society a 
similar case, obtained from a patient in Belle vue Hospital. The man 
from whom this specimen was taken was forty-five years old, and the 
fracture, occasioned by a fall upon the shoulder, extended from the 
sterno-clavicular articulation upwards and outwards one inch and a half. 
The fragments w T ere overlapped three-quarters of an inch, and were firmly 
united. The character of the accident was not recognized until after 
death. The specimen is now in the museum of the Belle vue Hospital. 

A case is reported from Mt. Sinai Hospital, in this city, of a fracture 
of the clavicle in an adult, at a point about one inch from the sternum. 
The inner fragment w T as drawn, by the action of the sterno-cleido-mas- 
toid muscle, into a vertical position, and the outer was drawn down upon 
the chest. It became apparent that replacement could not be effected 
without division of the muscle ; and inasmuch as the displacement caused 
no inconvenience, it was permitted to remain as it was found. 4 

With regard to the amount of displacement usually attendant upon 
fractures near the outer end of the bone, surgical writers have generally 
united in declaring that it was in a majority of cases very inconsiderable, 

1 Desault on Fractures, op. cit., p. 15. 2 Lonsdale on Fractures, p. 206. 

3 Malgaigne, op. cit., p. 491. 

4 New York Med. Journ., Jan. 1877, p. 48. 



198 FRACTURES OF THE CLAVICLE. 

while some have even affirmed that there would be found no displace- 
ment whatever ; neither of which opinions, according to the observations 
of Robert Smith, of Dublin, is strictly correct. He has examined eight 
specimens of fracture of the outer extremity of the clavicle, contained in 
the museum of the Richmond Hospital School of Medicine ; three of 
which were broken between the conoid and trapezoid ligaments, and are 
united with very little displacement, while the remaining five, broken 
beyond the trapezoid ligament, present a very marked deformity. 

The following is a summary of the conclusions to which he has 
arrived : — 

" When the clavicle is broken between the two fasciculi of the coraco- 
clavicular ligament, there is seldom any displacement of either fragment, 
and always much less than in fracture of any other portion of the bone. 
When displacement does occur, it is usually limited to a slight alteration 
in the direction of the bone, by which the natural convexity of this por- 
tion of the clavicle is increased. 

" The explanation of which facts is found in the attachments of the 
ligaments from below to the two fragments ; and in the action of the 
trapezius from above, by which they are antagonized. 

" But the case is very different when the bone is broken external to 
the trapezoid ligament. Here the coraco-clavicular ligaments can have 
no direct influence upon the outer fragment, which is displaced now partly 
by muscular action, and partly by the weight 
of the arm, the sternal end of the outer fragment 
being drawn upwards by the clavicular portion 
of the trapezius, while, by the action of the mus- 
cles passing from the chest, the entire outer frag- 
ment is drawn forwards and inwards, so as to 
bring sometimes its broken surface into contact 

Fracture outside of trapezoid ^ ^ anterior gurface of the inner f ragme nt, 
ligament. United. it. • • i • 1 1 • 

and placing it nearly at right angles with this 
fragment, in w r hich position it is generally united. The displacement in 
this direction, rather than any degree of overlapping, explains also the 
shortening which existed in all of these cases, varying in the different 
specimens from half an inch to one inch, and averaging about three- 
quarters of an inch." 

Such are the views of Mr. Smith, and I see no reason to call in ques- 
tion their correctness. In my own experience, a fracture occurring in 
a child three years old, within one inch of the acromial end, probably 
between the ligaments, was never displaced at all ; a second, and third, 
occurring in adults, presented no displacement. Two cases were dis- 
placed each one-quarter of an inch, and two cases, half an inch ; these 
four latter cases occurred in adults, and always within an inch of the 
acromial end of the bone. In one of these last examples, the inner frag- 
ment was rather behind than above the outer fragment. 

But it would be unsafe to draw conclusions from an experience which 
is confined entirely to living examples, and in which no dissections have 
been made, to verify the exact point of fracture, or the precise amount 
and character of the displacement. So far as they go, however, they 




FRACTURES OF THE CLAVICLE. 



199 



seem to me to confirm the general correctness of the observations made 
by Robert Smith. 

It has happened to me only six times to meet with a comminuted frac- 
ture of the clavicle, except in cases of gunshot injuries, all of which 
fractures occurred through some portion of the middle third of the bone ; 
the intercepted fragments being from one inch to one inch and a half in 
length, and lying obliquely, or, as in one case observed by me, at nearly 
a right angle with the main fragments. 

I have never seen a compound fracture of this bone except as the re- 
sult of a gunshot injury, although, in many cases, the sharp point of an 
oblique fracture has seemed just ready to penetrate the skin. 

One case is reported as having been presented at St. Bartholomew's 
Hospital. It occurred in a boy fourteen years old, and was produced 
by his having been drawn into some machinery while it was in motion. 1 
Two similar cases are reported from the New York Hospital, as having 
been observed during the last ten years preceding the date of the report. 
The whole number of fractures of the clavicle during this period was 191. 2 

Lente also mentions a case, seen by himself, occasioned by the fall of 
a derrick upon the shoulder. The patient, twenty-four years old, was 
admitted into the New York Hospital in August, 1848. The left clavicle 
was broken at about its middle, and a large wound in the integuments 
communicated with the fracture. The fragments united firmly in about 
six weeks, after several pieces of bone had been discharged from the 
wound. 3 

A double fracture, or a simultaneous fracture occurring in both clavi- 
cles, seldom occurs. I have recorded two cases {four fractures, three 
of which are incomplete), both oc- 
curring in young boys. 4 Mal- 
gaigne says it has only happened 
once in 2358 cases at the Hotel 
Dieu, and he can recollect only 
five other examples. And of 158 
cases of broken clavicles reported 
from the New York Hospital, it 
is stated to have occurred in only 
four. 

These gentlemen, however, only 
report hospital cases, and they 
have reference, doubtless, to com- 
plete fractures ; while double frac- 
tures, according to my experience, 
occur more often in children than 
in adults, and are of the character 
of partial fractures, without usu- 
ally much displacement ; which 

r \ . c . x , , , Complete Fracture.— Oblique ; at junction of outer 

tactS, it SUStamed by Subsequent and middle thirds. (From nature.) 



Fig. 46. 




1 London Med. Graz., vol. ii. p. 382. 

2 New York Med. Times, March 3 6, 1861. 

3 Lente, N. Y. Journ. of Med., July, 1850. 

4 Rep. on Del', after Frac, Cases 5, 6, 10. 



200 FRACTURES OF THE CLAVICLE. 

observations, would sufficiently explain their infrequency in hospital, 
and their relative frequency in private experience. 

Symptoms. — In all cases of complete fracture with displacement, no 
difficulty will be experienced in deciding upon the nature of the injury. 

The patient is found generally leaning toward the injured side, while 
the opposite hand sustains the elbow of the same side, to prevent its 
dragging downwards. 

The shoulder falls downwards, forwards, and inwards ; while, at the 
same time, the line of the bone is interrupted by the sharp and project- 
ing point of the sternal fragment. 

If the fracture is the result of a direct blow, a swelling and discolor- 
ation may be seen at the seat of fracture ; but if it is the result of a 
counter-stroke, we must look to the top or point of the shoulder for the 
signs of a contusion. 

The patient also experiences pain when an attempt is made to raise 
the arm at a right angle with the body, and especially in attempting to 
carry the arm across the body, by which the ends of the broken clavicle 
are driven into the flesh. In two cases (Cases 19 and 50 of my Report 
on Deformities) of oblique fracture, accompanied with displacement, 
occurring in the middle third of the bone, I have particularly noticed 
that the patients could easily lift the hands to the head, and in one of 
these cases the patient, a boy fourteen years old, raised his arm perpen- 
dicularly over his head. Such exceptions are not very uncommon. 

Crepitus can be detected sometimes by simply pressing down the 
sternal fragments, but it is almost always present when we draw the 
shoulders forcibly back, so as to bring the broken fragments into more 
perfect contact. 

If there is no displacement, still crepitus may generally be discovered 
by grasping the bone between the thumb and fingers, and moving it 
gently up and down, or by slight pressure upon the point of fracture. 

When the fracture occurs close to the acromial extremity, external to 
the coraco-clavicular ligaments, quite frequently there is no perceptible 
or marked displacement, and its diagnosis will require, therefore, more 
care and attention on the part of the surgeon. 

Prognosis in this fracture deserves especial attention. In no other 
bone, except the femur, does a shortening so uniformly result. Of 
seventy-two complete fractures only sixteen united without shortening ; 
and of twenty-seven simple, oblique, complete fractures, which occurred 
at or near the outer end of the middle third, only one united without 
shortening (Case 46 of my Report), and in this case the patient was 
but fifteen years old, and the fragments were never much displaced; 
nor can I say that the treatment — a board across the back, after the 
manner of Keckerley — had anything to do with the result. Six cases 
of complete transverse fracture, occurring at the same point, united 
without shortening. 

The shortening, after the union is consummated, varies from one- 
quarter of an inch to one inch or more ; and the fragments are almost 
always, especially when the fracture is through the middle third, found 
lying in the position in which we have described them to be at the first; 
the outer end of the inner fragment being above, and often a little in 



FRACTURES OF THE CLAVICLE. 



201 



front of, the outer; sometimes, especially in lean persons, and when the 
fractures are very oblique, presenting a sharp and unseemly projection. 

The greatest amount of shortening is generally found in those frac- 
tures which occur through the middle third, or, as Dawson has correctly 
said, between the rhomboid and coraco-clavicular ligaments. 1 In frac- 
tures near the sternal end, within the region occupied by the rhomboid 
ligament, there is usually very little permanent displacement. The 
same is true when the fracture is at the acromial end, and between the 
fasciculi of the coraco-clavicular ligaments, as the observations of Robert 
Smith, already quoted, have sufficiently established; but if the fracture 
is beyond these ligaments, near the acromial end, the final displacement 
and deformity may be very great. 

The presence of a small amount of ensheathing callus soon after the 
cure is completed, sometimes increases the deformity. It is rarely 
seen to encircle the bone completely, and occasionally it appears to be 
most abundant in the direction of the salient points of the fracture, that 
is, above and below ; so that, unless the examination is made with care, 
the projecting points of callus which remain, sometimes after many years, 
may be easily mistaken for an intercepted fragment turned at right 
angles to the axis of the bone. 

Robert Smith has observed, also, that in cases of fracture external to 
the conoid ligament, osseous matter is freely formed upon the under 
surface of each fragment, but there 
is seldom any deposited upon the 
upper surface of either. These os- 
seous growths, occupying the situa- 
tion of the coraco-clavicular liga- 
ments, frequently prolong themselves 
as far as the coracoid process, and 
in some cases to the notch of the 
scapula. Still less frequently these 
osteophytes become fused with the 
coracoid process, and a true anchylo- 
sis exists. 

In comminuted fractures the inter- 
cepted fragments generally fall off 
from the line of the other fragments, 
and cannot easily be restored. 

The clavicle, being a spongy and 
vascular bone, usually unites with 
great rapidity, generally within twen- 
ty days. In the fourth example of 
transverse fracture already mentioned as having been seen by me, the 
union seemed to be tolerably firm in seven days. Wallace reports one 
case from the Pennsylvania Hospital, which was cured in eight days, 
and another in nine days. 2 Velpeau says the clavicle will unite in from 




Comminuted Fracture. — United. 
(From nature.) 



1 W. W. Dawson, M.D., Prof. Surgery Med. Col. Ohio, 
nati, Jan. 5, 1878. 

2 Am. Journ. Med. ScL, vol. xvi. p. 115. 

14 



The Clinic," -Cincin- 



202 FRACTURES OF THE CLAVICLE. 

fifteen to twenty-five days ; Benjamin Bell, in fourteen; Stephen Smith 
has seen it firm in fifteen days. 

Whatever may be the degree of displacement, or the condition of the 
system, unless in a case of gunshot fracture, it is very seldom that it 
refuses to unite altogether, or that the union is ligamentous. In Muhlen- 
berg's tables of 656 cases of delayed and non-union of long bones, there 
is but one example of non-union of the clavicle. And in the few cases 
found upon record of a ligamentous union, the functions of the arm do 
not seem to have suffered any serious ultimate injury, as the following 
example will illustrate: — 

Edmund Nugent, a stout Irish laborer, twenty-five years old, was 
received into the Buffalo Hospital of the Sisters of Charity, in March, 
1854. Several years before, he fell from a horse, and broke his left 
clavicle, at the outer end of the middle third. This was near Cork, 
in Ireland; and, without consulting any surgeon or "handy man," he 
continued at work, holding the tail of the plough, nor from that day 
forward did he employ a surgeon, or dress his arm, or cease from his 
work. 

The clavicle presented the same deformity which many other similar 
fractures present after what is usually termed successful treatment, 
except that it was not united by bone. The outer end of the inner frag- 
ment rode upon the inner end of the outer fragment half an inch. The 
ligament uniting the two extremities was so long and firm that it could 
be distinctly felt, and the fragments moved upon each other with great 
freedom. 

In order that we might determine the amount of injury which he had 
suffered from the ligamentous union, we directed him to lift weights 
placed on a table before him, while he was seated upon a chair. We 
ascertained from this experiment that with his left arm he could lift as 
much, within three ounces, as he could with his right, and he was not 
himself conscious of any difference. The muscles of the left arm seemed 
as well developed as those of the right. 

In May, 1868, I found in the Charity Hospital, Blackwell's Island, 
in the person of A. Bragg, set. 34, a fracture of the left clavicle, which 
had united only by ligament. The fracture had occurred, when he Was 
twenty years old, at about the junction of the outer fourth with the 
inner three-fourths. No surgeon was employed, and no treatment had 
ever been adopted. The ligament was quite long, and the fragments 
moved freely upon each other, yet the arm was nearly as strong and as 
useful as before. 

Chelius also refers to two cases mentioned by Gurdy and Velpeau, in 
which, although an artificial joint remained, the use of the limb was but 
little impaired. 1 

In a case of compound and comminuted gunshot fracture reported by 
Ayres, of New York, the recovery was remarkable. The man was sixty- 
two years old, and in excellent health, when the injury was received. 
The clavicle was so extensively comminuted that before the wound closed 
over one-third of the bone had escaped, and yet at the end of one year 

1 Chelius, Ainer. ed., vol. i. p. 603. 



FRACTURES OF THE CLAVICLE. 203 

from the time of the accident the shoulder was perfectly symmetrical 
with its fellow, without drooping or falling forwards. Dr. Ay res thinks 
that all of the clavicle which was lost had been reproduced. 

A partial paralysis, with atrophy of the muscles of the arm, accom- 
panied, also, with more or less rigidity and contraction of the muscles 
both of the arm and forearm, is, according to my observation, a more 
frequent result of these fractures. 

Mr. Earle has recorded a case of comminuted fracture of the clavicle, 
in which the nerves converging to form the axillary plexus were so much 
injured that paralysis of the arm ensued ; and it w r as noticed as an inter- 
esting fact, that the patient could not afterwards put her hand into even 
moderately warm water without the effects of a scald being produced, 
characterized by vesications, redness, etc. 1 

Desault saw a case at Hotel Dieu, in which, although the clavicle was 
not broken, the force of the blow upon the clavicle was sufficient to pro- 
duce a severe concussion of the brachial plexus, and paralysis of the arm. 
A timber had fallen from a building, striking upon the external part of 
the left clavicle. A considerable wound, followed by swelling, pointed 
out the place on which the blow had been received. No apparatus was 
applied, and on the third day a numbness and partial loss of the power 
of motion occurred in the arm of the affected side. Soon afterward an 
insensibility came on, and by the seventh day the paralysis of the arm 
was complete. It was not until after a tedious treatment that the limb 
recovered in part its original strength. 2 

In Case 23 of my report to the American Medical Association, which 
was followed by paralysis of the opposite arm, and spinal curvature, 
these results w T ere probably due to some injury of the back received at 
the time of the accident ; but one cannot avoid a suspicion that the 
apparatus, Brasdor's jacket, contributed somewhat to the unfortunate 
result. No axillary pad was employed, but the straps over each 
shoulder were buckled so tight that he was compelled to incline his 
head constantly to the right side. He was unable to lie down, and 
could only incline in a half-sitting posture. This treatment was con- 
tinued four weeks : and two months after its removal the paralysis and 
spinal distortion commenced. 

In Case 38, also, of the same report, a comminuted fracture, paralysis 
with contraction of the muscles extending to the wrist and fingers existed, 
but whether it was due to the severity of the original injury or to the 
treatment, could not be satisfactorily ascertained. 

Gibson relates a remarkable instance of this kind. A young man 
was struck on the clavicle by the falling limb of a tree, breaking it into 
numerous pieces, and bruising the parts so severely as to give rise to 
violent inflammation. " The fragments had been driven behind and 
beneath the level of the first rib, and so compressed the plexus of 
nerves as to wedge them into each other, and by the subsequent in- 
flammation to blend them inseparably together. Complete paralysis 
and atrophy of the whole arm ensued, and the patient's object in visit- 

1 S. Cooper's First Lines, fourth Amer. ed., vol. ii. p. 323. 

2 Desault on Frac. and Disloc, Amer. ed., p. 14, 1805. 



204 FRACTURES OF THE CLAVICLE. 

ing Philadelphia was to submit to an operation, in hopes of elevating 
the clavicle to its natural height, and taking off pressure from the 
nerves." Dr. Gibson, however, did not believe that the prospect of 
success was sufficient to warrant the operation, and the young man was 
sent home. 1 

It will not do to deny, therefore, the possibility of a paralysis as re- 
sulting from a concussion of the axillary nerves, produced by a blow 
upon the clavicle, nor of a paralysis resulting from a direct injury in- 
flicted by the points of the fragments upon this plexus in certain very 
badly comminuted fractures ; but it is certain that these conditions 
will not satisfactorily explain all of the examples in which paralysis 
has followed simple fractures. In some cases it is no doubt due rather 
to the injudicious mode of using an axillary pad, by means of which 
the arm is converted into a powerful lever, and thus the brachial nerves 
are made to suffer from compression along the inner side of the arm 
itself. In short, it must be confessed that it is sometimes due to the 
treatment alone, and not to the original injury. 

Parker, of New York, in a note to the edition of S. Cooper's Sur- 
gery, just quoted, declares that he has seen one patient who had lost 
the use of his arm from the pressure upon the nerves by the wedge- 
shaped pad, over which the limb was confined, in order to pry the 
shoulder outwards. Stephen Smith mentions a case of partial paralysis 
from the same cause. 2 

A similar case has come under my own observation. 'A lady, aged 
fifty-one years, was thrown from her carriage, breaking the right clav- 
icle obliquely at the outer end of the middle third. During the first 
three weeks the arm was dressed with Fox's apparatus, which was at 
no time particularly painful. She was then placed under the care of 
another surgeon, who, finding the fragments overlapped, applied very 
firmly a figure-of-8 bandage, with an axillary pad, securing the arm 
snugly to the side of the body ; hoping by these means to restore the 
fragments to their place. The pain which followed was excessive, and, 
notwithstanding the free use of anodynes, it became so insupportable 
that at the end of fourteen hours the dressings were removed by another 
surgeon, and Fox's apparatus again substituted. These were also ap- 
plied much more tightly than at first, and during the four weeks longer 
that they remained on, repeated attempts were made to reduce the 
fragments. 

Forty-eight days after the accident, she consulted me. The clavicle 
was then united, and overlapped half an inch. The whole arm was 
swollen, painful, and very tender, with total inability to move it. 

I removed all the dressings, and, during the time she remained under 
my care, in a private room at the hospital, there was a gradual improve- 
ment in the condition of her arm, in respect to swelling and tenderness, 
but the paralysis did not much abate. 

Erichsen thinks he has seen one case of comminuted fracture, pro- 
duced by a direct blow, in which the subclavian vein was ruptured ; great 

1 Gibson, op. cit., 6th ed., vol. i. p. 271. 

2 New York Journ. of Medicine, May, 1857. 



FRACTURES OF THE CLAVICLE. 205 

extravasation of blood resulted, and the arm was threatened with gan- 
grene. The patient having recovered, however, the diagnosis could not 
be determined by actual dissection. 1 

Since among surgeons some difference of opinion seems to exist as to 
the practicability of overcoming the displacement in certain fractures of 
the clavicle, it is proper that I should defend the accuracy of my own 
observations by a reference to the observations of others. 

In nine of eleven cases reported by Stephen Smith, one of the sur- 
geons at Bellevue Hospital, New York, more or less deformity remained 
after the cure was completed. In the two remaining cases the actual 
results are unknown. 2 

Chelius remarks : " Setting of this fracture is easy, yet only in very 
rare cases is the cure possible without any deformity." . . . . " It is 
considered, also, that the close union of the fracture of the collar-bone 
depends less on the apparatus than on the position and direction of the 
fracture (therefore, in spite of the most careful application of this appa- 
ratus, some deformity often remains)." 3 

Velpeau, in a lecture given in 1846, and published in the Grazette 
des Hdpitaux, declares that with all the bandages imaginable, in the 
case of an oblique fracture at the junction of the outer third with the 
inner two-thirds, we cannot prevent deformity. 

Yidal observes : " Fracture of the clavicle is almost always followed 
by deformity, whatever may be the perfection of the apparatus and the 
care of the surgeon." 4 

" Hippocrates has observed that some degree of deformity almost 
always accompanies the reunion of a fractured clavicle ; all writers 
since his time have made the same remark ; experience has confirmed 
the truth of it." 5 

Turner remarks as follows: "As to the reduction of this fracture, it 
must be owned the same is often easier replaced than retained in its 
place after it is reduced ; for its office being principally to keep the 
head of the scapula, or shoulder, to which, at one end, it is articulate, 
from approaching too near, or falling in upon the sternum, or breast- 
bone, it happens that, on every motion of the arm, unless great care be 
taken, the clavicle therewith rising and sinking, the fractured parts are 
apt to be distorted thereby. Besides, even in the common respiration, 
the costse and sternum aforesaid, where the other end of this bone is 
adnected, together with the motion of the diaphragm, rising and falling, 
especially if the same be extraordinary, as in coughing and sneezing, 
are able to undo your work, not to mention the situation thereof, less 
capable of being so well secured by bandage as many others. All which, 
duly considered, it is no wonder that upon many of these accidents, 
although great care has been taken, these bones are sometimes found to 

1 Ericlisen, Surgery, Amer. ed., p. 205. 

2 New York Journ. Med., May, 1857, p. 382. 

3 System of Surgery. By J. M. Chelius, of Heidelberg, with notes by South. First 
Amer. ed., vol. i. pp. 603/605. 

4 Vidal (de Cassis), Paris ed., vol. ii. p. 105. 

5 Treatise on Fractures and Luxations. By J. P. Desault. Edited by Xav. Bichat, 
and translated by Charles Caldwell, M.D. Philadelphia, 1805, p. 9. 



206 FRACTURES OF THE CLAVICLE. 

ride, and a protuberance is left behind, to the great regret particularly 
of the female sex, whose necks lie more exposed, and where no small 
grace or comeliness is usually placed." 1 

Says Johannis de Gorter : " Restituiter facile tractis humeris a min- 
istro posterius, dum simul suo genu locato ad spinam dorsi, dorsum sus- 
tentet minister, nam tunc chirurgus folis digitis claviculam fractam re- 
ponere potest. Difficilius autem in reposita sede retinetur, sed loca 
cava supra et infra claviculam spleniis implenda." 2 

Says Heister, writing only a little later : " The reduction of a broken 
clavicle is not very hard to be effected, especially when the fracture is 
transverse ; nor is it unusual for the humerus, with the fragment of the 
clavicle, to be so far distorted as not to be easily replaced with the fingers ; 
but the difficulty is much greater to keep the bone in its place when the 
fracture is once reduced, especially if the bone was broken obliquely ." 3 

Amesbury, after having exposed the inefficacy of all previous modes 
of dressing, and especially of the figure-of-8 bandage, Desault's, Boyer's, 
and an apparatus recommended by Sir Astley Cooper, proceeds to describe 
his own apparatus and to affirm its excellence. It is, however, not much 
unlike a multitude of others, and is liable to the same objections. 4 

M. Mayor, of Lausanne, thinks that up to this day no successful mode 
of treatment has been devised. "Here everything appears as yet so 
little determined, that each day sees some new propositions and different 
procedures," etc. He believes, however, that in his simple handkerchief 
bandage, with straps across each shoulder, the indications are most fully 
accomplished and the most successful results are obtained. If, however, 
it were to be treated without apparatus, the horizontal position, lying 
upon the back, would, in the end, make the most perfect unions. 5 

Says M. Malgaigne: " The prognosis, considering the trivial character 
of this fracture, is sufficiently difficult. For, little as may be the dis- 
placement, the surgeon ought not to promise a reunion without deformity ; 
and certain successful results, proclaimed from time to time, betray, on 
the part of those who relate them, the most extravagant exaggerations." 6 

M. Nelaton having spoken of the various plans which have been sug- 
gested to retain this bone in place, and of their inefficiency, comes at last 
to speak of the handkerchief bandage of M. Mayor, and remarks : — 

" This apparel is very simple ; but neither will it remedy the over- 
lapping." .... " Of all the apparels which we have passed in review, 
there is, then, not one which fills completely the three indications usually 
present in the fracture of a clavicle. None of them oppose the displace- 
ment ; they have no effect, with whatever care they may be applied, but 
to maintain immobility in the limb. We think, then, that it is useless 
to fatigue the patient with an apparatus annoying, and, perhaps, even 



1 The Art of Surgery, by Daniel Turner, vol. ii. p. 256. London ed., 1742. 

2 Johannis de Gorter ; Chirurgia Repurgata, p. 79. Lugduni Batavorum, 1742. 

3 Heister's Surgery, vol. i. p. 134. Lond. ed., 1768. 

4 Treatment of Fractures, by Joseph Amesbury, vol. ii. p. 527. London ed., 1831. 

5 Nouveau Systeme de Deligation Chirurgicale, par Mathias Mayor, de Lausanne, 
p. 384, etc. (also Atlas, plate 3, figure 23). Paris ed., 1838. 

6 Traite des Fractures et des Luxations, par J. F. Malgaigne, tome premier, p. 473. 
Paris ed., 1847. 



FRACTURES OF THE CLAVICLE. 207 

painful ; a simple sling, secured upon the sound shoulder, will be suffi- 
ciently severe. Nevertheless, as this does not assure so complete im- 
mobility as the bandage of M. Mayor, it is to this that we think the 
preference ought be given in all cases of fractures of the clavicle, whether 
accompanied with displacement or not, whether they occupy the middle 
or the external part of the clavicle. If the fracture presents no dis- 
placement, we shall obtain a cure which will leave nothing to be desired. 
If there is a tendency to displacement, the consolidation will be effected 
with a deformity more or less marked ; but since this deformity is in- 
evitable, at least with adults, whatever may be the apparel which we 
employ, it is evident that the apparatus which causes the least constraint 
ought to have the preference. We may remark, farther, that this union 
with deformity in no wise impairs the free exercise of all the movements 
of the members." 1 

" The venerable gentleman who stands at the head of American sur- 
gery, and whose manipulations with the roller approach very nearly to 
the limits of perfection, informed us, in 1824, that he had never seen a 
case of fractured clavicle cured by any apparatus, without obvious de- 
formity." 2 

I need not say that the " venerable gentleman" to whom Dr. Coates 
refers in this passage was the late Dr. Physick, of Philadelphia. 

Dr. Gross says that, according to his experience, "fractures of the 
clavicle are seldom cured without more or less deformity, whatever pains 
may be taken to prevent it." 3 

Among the late German authors Roser speaks as follows : " The treat- 
ment of fractures of the clavicle is, after all that has been said, very 
imperfect ; and it is very often the case that, after a most careful treat- 
ment, some deformity will remain, such as protrusion of the inner frag- 
ment, crossing of the fragments, and consequent shortening." 4 

Says Bryant, in his excellent Treatise on Surgery : " Deformity almost 
always exists in spite of treatment." 5 

Treatment. — If evidence were needed beyond that which has been 
furnished, of the difficulty of bringing to a successful issue the treatment 
of this fracture, it might be supplied, one would think, by a reference 
merely to the immense number of contrivances which have been at one 
time and another recommended. 

A catalogue of the names only of the men who have, upon this single 
point, exercised their ingenuity, would be formidable, nor would it present 
any mean array of talent and of practical skill. 

All these surgeons, however, have admitted the same indications of 
treatment, viz., that in order to a complete restoration of the outer frag- 
ment, which alone is supposed to be much displaced, we are to carry the 

1 Elements de Pathologie Chirurgicale, par A. Nelaton, tome premier, p. 720. 
Paris ed., 1844. 

* Reynell Coates, Amer. Med. Journ., vol. xviii. p. 62, old series. It is probable 
that Dr. Physick here referred to complete and oblique fractures of the middle third, 
or that Dr. Coates has forgotten the precise language employed on this occasion. 

3 Cross, System of Surgery, vol. i. p. 954, 1872. 

4 W. Roser, Handbuch der Anatomischen Chirurgie, 6 Aufi., Tubingen, 1872. 

5 Bryant, Practice of Surgery, 1872, p. 927. 



208 FEACTURES OF THE CLAVICLE. 

shoulder upwards, outwards, and backwards. But as to the means by 
which these indications can be most easily, if at all, accomplished, the 
widest differences of opinion have prevailed ; and, in the debate, it may 
be seen that while, on the one hand, no invention has wanted for both 
advocates and admirers, on the other hand, no' method has escaped its 
equivalent of censure. 

Hippocrates, Celsus, Dupuytren, Flaubert, Lizars, Pelletan, and 
others, directed the patients to lie upon their backs, with little or no 
apparatus. S. Cooper and Dorsey also recommend that the patients 
should be confined in this position during most of the treatment ; and 
from the account given by Dr. Lente, it will be understood that a simi- 
lar plan was at one time adopted in the New York City Hospital. " But 
this result," speaking of angular deformity, not overlapping of the frag- 
ments, " rarely happens when the patient has strictly followed the direc- 
tions of the surgeon, as to position especially, for it is by position, more 
than by any other remedial means, that a good result is to be effected." 

Nearly the same method Ave find recommended by Alfred Post, in 
1840, then one of the surgeons of that hospital ; the arm being merely 
kept in a sling and bound to the side, with the patient lying upon his 
back. Dr. Post mentions a case treated in this manner, which termi- 
nated with very little deformity ; x and I have myself treated many cases 
by this plan, with more than average success. 

Dr. Edward Hartshorne, of Philadelphia, has published, in the second 
volume of the Pennsylvania Hospital Reports, 1869, a very ingenious 
argument in favor of the supine position, in which he seems to have 
demonstrated that the special efficacy of this plan depends upon the 
pressure made upon the angle of the scapula. In order to accomplish 
this, and to place the scapula in the position most favorable for the 
reduction of the clavicle, the back should rest upon a broad, firm, and 
unyielding mattress, and not upon a pillow between the shoulders, which 
latter has the effect rather to defeat than to promote the indication ; the 
head should be slightly raised so as to relax the sterno-cleido-mastoid 
muscles and somewhat extend the trapezius ; the arm and forearm of the 
injured side should be flexed, resting across the chest, with the hand 
reaching over the sound shoulder, as recommended by Velpeau in the 
use of his dextrin apparatus, or it should be placed at right angles with 
the body, as recommended by Dupuytren. Bryant, of London, recom- 
mends essentially the same method. 

It is scarcely necessary to say that the absolute immobility required 
by the posture treatment must always limit its application, and render 
its general employment impossible. Dr. J. A. Packard, of Philadelphia, 
regards the scapula, also, as the bone upon which the restoration of the 
clavicle chiefly depends ; and he finds in the serratus magnus the especial 
obstacle to this restoration. 2 

Dr. Eve, of Nashville, Tenn., and Dr. Eastman, of Broome County, 
N. Y., have also employed this method successfully; 3 while Malgaigne 
declares it to be the most reliable means of obtaining an exact union. 

i N. Y. Journ. of Med., vol. ii. p. 226. 

2 Packard, New York Journ. of Med., 1867. 

3 Bost. Med. and Surg. Journ., vol. lvi. p. 468. 



FRACTURES OF THE CLAVICLE. 



209 



Fig. 48. 



Albucasis, Lanfranc, Guy de Chauliac, Petit, Parr, Syme, Skey, 
Brunningliausen, and very many others, especially among the English, 
have preferred, in order to carry the shoulders back, a figure-of-8 ; while 
Desault, Colles, South, Bryant, and Samuel Cooper have represented 
this bandage as useless, annoying, and mischievous. 

Heister, Chelius, Miller, Breffield, Keckerly, 1 Coleman, 2 Hunton, 3 
prefer, for this purpose, some form of back-splint, extending from acro- 
mion to acromion, against which the 
shoulders may be properly secured. 
Parker says that splints of this kind, 
with a figure-of-8 bandage, are "better 
than all the apparatus ever invented," 
while Mr. South gives his testimony in 
relation to all dressings of this sort as 
follows : " I do not like any of the ap- 
paratus in which the shoulders are drawn 
back by bandages, as these invariably 
annoy the patient, often cause excoria- 
tion, and are never kept long in place, 
the person continually wriggling them 
off to relieve himself of the pressure." 

Fox, 4 Brown, 5 Desault, and others 
bring the elbow a little forwards, and 
then lift the shoulder upwards and back- 
wards. Wattman and Lonsdale carry 
the elbow still farther forwards, so as 
to lay the hand across the opposite shoulder ; while Guillou carries the 
hand and forearm behind the patient, and then proceeds to lift the 
shoulder to its place. Moore, also, recommends that the elbow shall be 
carried back. 

Thus Desault, Pox, and Wattman accomplish the indication to carry 
the shoulder back, by lifting the humerus, with the elbow in front of the 
body ; while Guillou and Moore accomplish the same indication by lift- 
ing the humerus when the elbow is a little behind the body. Chelius 
also says: " The elbow, as far as possible, is to be laid backwards on 
the body." 

Sargent, who believes that with Fox's apparatus " the occurrence of 
deformity is the exception," and not the rule, and prefers it to all others, 
has treated three cases by Guillou's method, and is perfectly satisfied 
with its operation. Hollingsworth, of Philadelphia, has also treated one 
case successfully by Guillou's method, and adds his testimony in its 
favor. Several surgeons think they have obtained equal success with 
Moore's apparatus. 




Pisrure-of-S. 



1 Keckerly, Amer. Journ. Med. Sci,, vol. xv. p. 115 ; also, my Report on Deformi- 
ties after Fractures, in Trans, of Amer. Med. Assoc, vol. viii. p. 440. 

2 Coleman, New York Journ. Med., second series, vol. iii. p. 274. from New Jersey 
Med. Rep. 

3 Hunton, ibid. ; also, New Jersey Med. Rep., vol. v. p. 146. 

4 Fox, Liston's Practical Surgery, Amer. ed., p. 47. 

5 Browu, Sargent's Minor Surgery, -p. 132. 



210 FRACTURES OF THE CLAVICLE. 

But how shall we explain these equal results from opposite modes of 
treatment ? Is the indication to carry the shoulders back, which Fox 
sought to accomplish by pressing the elbow upwards and backwards, as 
easily attained by pressing the elbow upwards and forwards? Or are 
we not compelled to infer that there has been some mistake as to the 
precise amount of good accomplished by the apparatus in either case ? 
Moreover, Coates, 1 Keal, and others instruct us that the only safe and 
proper position for the humerus is in a line with the side of the body, 
and that it must neither be carried forwards nor backwards. 

PaulusiEgineta, Boyer, Desault, Pecceti, Liston, Fergusson, Samuel 
Cooper, Erichsen, Miller, Skey, Levis, Dorsey, 2 Gibson, 3 Fox, H. H. 
Smith, 4 Norris, 5 Sargent, Eastman, 6 recommend an axillary pad ; while 
Richerand, Yelpeau, Dupuytren, Benjamin Bell, Syme, Moore, deny its 
utility, or affirm its danger. Dr. Parker has seen one patient in whom 
paralysis of the arm resulted from the pressure upon the brachial nerves, 
in the attempt " to pry the shoulder out;" and I have myself recorded 
another. 

Cabot, of Boston, Massachusetts, has recommended a mould of gutta 
percha laid over the front and top of the chest. 7 

Desault's plan, which took its origin, as Velpeau thinks, in the spica 
of Glaucius, under various modifications, is recommended by Delpech, 
Cruveilhier, Lasere, Flamant, Samuel Cooper, Fergusson, Liston, Cut- 
ler, Physick, Dorsey, Coates, and Gibson ; while by Velpeau, Syme, 
Colles, Chelius, Samuel Cooper, and Parker, it is regarded as inefficient 
and troublesome. Says Mr. Cooper: " In this country, many surgeons 
prefer Desault's bandages; but I do not regard them as meeting the 
indications, and consider them worse than useless." 

The dextrin bandages, or apparatus immobile, of Blandin, Velpeau, 
and others, constitute only another form of the bandage dressing of De- 
sault. In this connection it ought to be noticed that Velpeau does not 
regard the employment of this apparatus, or of any other demanding 
great restraint, as imperative. In his great work on anatomy, referring 
to the fact that when the bone is broken and overlapped, the patient is 
still able, in many cases, to move the arm freely, he remarks: "Do not 
these cases give support to the opinion of those who admit that fractures 
of the clavicle do not actually require any other apparatus than the 
simple supporting bandage?" "It is necessary to observe," he adds, 
"that by thus acting we do not prevent an overlapping," 8 etc. 

According to Flower and Hulke, authors of the article on " Injuries 
of the Upper Extremities" in the last edition of Holmes's Surgery, in 
most of the hospitals in London the surgeons employ a moderate-sized 
pad in the axilla, and then secure the arm to the body with a broad 

1 Coates, Am. Journ. Med. ScL, vol. xviii. p. 62. 

2 Dorsey, Elements of Surgery, vol. i. p. 133. 

3 Gibson, Institutes and Practice of Surgery, vol. i. p. 271. 

4 H. H. Smith, Practice of Surgery, p. 354. 

5 Norris, Liston's Practical Surg., Amer. ed., p. 46. 

6 Eastman, Apparatus for Fractured Clavicle, by Paul Eastman, Aurora, 111. ; 
Boston Med. and Surg. Journ., vol. xxiii. p. 179, 

7 Cabot, Bost. Med. and Surg. Journ., vol. lii. p. 232. 

8 Velpeau, Anatomy, Amer. ed., vol. i. p 242. 



FRACTURES OF THE CLAVICLE. 



211 



calico roller, some of the turns of which are made to pass beneath the 
elbow and over the opposite shoulder. Some of the surgeons advance 
the elbow, others carry it back, but a majority permit it to hang per- 
pendicularly beside the body. As will be hereafter seen, this plan is 
essentially the same as that adopted by myself. 

Professor E. M. Moore, of Rochester, in a paper read before the 
New York State Medical Society, in 1871, has called attention to what 
he terms the "Figure-of-8 from 

the elbow," by which he pro- Fig. 49. 

poses to render tense the clavi- 
cular fibres of the pectoralis ma- 
jor, and at the same time draw 
the scapula backwards toward 
the spine. He is thus able, he 
affirms, to overcome the action 
of the sterno-cleido- mastoid, 
which lifts the sternal fragment ; 
and to draw the acromial frag- 
ment outwards and upwards. 

These ends are accomplished 
by placing the extremity of the 
middle finger of the broken arm 
upon the ensiform cartilage, with 
the forearm and elbow pinned 
back and against the body. In 
order to secure the arm in this 
position, "I use," says Dr. 
Moore, " a shawl or piece of 
cotton cloth, which, when folded 
like a cravat, eight inches in 
breadth at the centre, should be 
about two yards long. Placing 
this at the centre across the palm of the surgeon, he seizes with this 
hand the elbow of the patient which corresponds with the broken clavi- 
cle. The two ends of the bandage hang to the floor. The one falling 
inward toward the patient is carried upward, in front of the shoulder 
and over the back, making a spiral movement in front of the shoulder. 
This is intrusted to an assistant. The outer end is then carried across 
the forearm, behind the back, over the opposite shoulder, and around 
the axilla. This meets the other end, which may be carried under the 
axilla and over the shoulder of the opposite side, thus making the figure 
(8) turn, around the sound shoulder. This twist, it will be seen, 
makes also the figure eight (8) turn, around the elbow of the affected 
side. I therefore style the bandage, ' The elbow figure eight (8).' " 

" The forearm should be sustained by a sling which raises it to an 
acute angle in order that gravity may assist in moving the whole arm 
backward. This is best done by a simple strip three or four inches 
wide, which may be pinned to the shawl at the shoulder, or by a sling 
across the opposite shoulder and behind the back. The former much to 
be preferred. Any tendency on the part of the shawl to slide from the 




Moore's apparatus. Back view. 



212 



FRACTURES OF THE CLAVICLE. 




Yig. 50. shoulder may be arrested by a 

pin thrust at the crossing. The 
shawl at the elbow is kept in 
place by folding the upper part 
that fits the arm and securing it 
by a pin. This makes a sort of 
cup for the elbow." 

The principle upon which this 
dressing is constructed, appears 
to me sound ; but hitherto, in 
the five or six cases in which it 
has been employed under my 
observation, it has failed to ac- 
complish any more than is ac- 
complished by many other forms 
of dressing. It is especially 
liable to become disarranged, 
and to cause excoriations in the 
sound axilla; in this respect 
being quite as obnoxious to 
criticism as the ordinary figure 
of eight. 

Dr. Lewis A. Sayre, of this 
city, has for some time employed 
an apparatus for dressing broken 
clavicles, F by which he proposes, also, to render tense the clavicular attach- 
ments of the pectoralis major, and thus secure more effectually the de- 
pression of the sternal fragment, while at 
the same time the shoulder is lifted and 
carried back. 

Two strips of adhesive plaster are pre- 
pared, each about three and a half inches 
wide, for an adult ; one long enough to 
encircle, first the arm, and then the body 
completely ; the other of sufficient length 
to reach from the sound shoulder, over 
the point of the elbow of the broken 
limb, and across the back obliquely to 
the point of starting. Maw's moleskin 
plaster, or some plaster equally strong, is 
to be preferred. 

The first strip is looped around the 
arm just below the axillary margin, and 
pinned, or stitched, with the loop suffi- 
ciently open to avoid strangulation. The 
arm is then drawn downwards and back- 
wards until the clavicular portion of the 
pectoralis major is put sufficiently on the 
sayre's apparatus. stretch to overcome the sterno-cleido-mas- 



Moore's apparatus. Front view. 



Fig. 51. 




FRACTURES OF THE CLAVICLE, 



213 



toid, and thus draw the sternal fragment of the clavicle down to its 
place. The strip of plaster is then carried completely around the "body, 
and pinned or stitched to itself on the back. 

The second strip is then applied, commencing on the front of the 
shoulder of the sound side, thence it is carried over the top of the 
shoulder, diagonally across the back, under the elbow, diagonally across 



Fig. 52. 



Fig. 53. 





the front of the chest, to the point of starting, where it is secured by 
pins or thread. A longitudinal slit is made in the plaster, to receive 
the point of the elbow. 

Before laying the plaster across the elbow, an assistant must press 
the elbow well forwards, and inwards, and it must be held firmly in this 
position until the dressing is completed. It will be now seen that the 
arm has been converted into a lever, whose fulcrum is the loop of ad- 
hesive plaster at the lower margin of the axilla ; and upon this it is 
believed that in a great measure the efficiency of the apparatus depends. 

Certainly it no longer depends upon the position of the elbow, which 
was at first carried back in order to render tense the clavicular fibres of 
the pectoralis major, since, for the purpose of converting the humerus 
into a lever, the elbow is subsequently drawn forwards, and the clavicu- 
lar fibres of the great pectoral are again relaxed. If, therefore, the 
apparatus has any advantages over other modes of treatment, it is 
solely by its action upon the humerus as a lever ; but the fulcrum is 
too remote from the upper end of the humerus to act very efficiently. 
Great force has to be applied to secure this end, or at least so much 
force that, if steadily maintained, it is pretty sure to cause excoriations 
of the arm where the fulcrum acts ; or, as more often happens, it will 
speedily loosen, under the expansion and contraction of the chest in 
respiration, and thus cease to be efficient. Several cases of fractured 



214 FRACTURES OF THE CLAVICLE. 

clavicles, treated in Bellevue and St. Francis hospitals by this method, 
have come under my notice, some of which were dressed by Dr. Sayre 
himself, and the results have been no better than when my apparatus has 
been used, while they have in most cases caused much more discomfort. 

Dr. Satterthwaite has substituted Martin's elastic bandage for the ad- 
hesive plasters, and has devised a water bag to be used as an axillary 
pad, constructed in the form of a horse-shoe, which he says " has given 
entire satisfaction in the two instances in which it was applied." 1 From 
w r hich I must infer that he is satisfied with a union accompanied with 
some overlapping of the fragments; a conclusion to which most other 
experienced surgeons have arrived. 

The sling, in some of its forms, is employed by Richerand, Huberthal, 
Colles, Miller, Fox, Stephen Smith, 2 H. H. Smith, Bartlett, 3 Levis, 4 
Dugas, 5 Benjamin Bell, Bransby Cooper, Earle, Chapman, Keal, and by 
a large majority of the English surgeons. 

No apparatus, perhaps, has been so generally employed, among 
American surgeons, as that form of the sling introduced by Dr. George 
Fox into the Pennsylvania Hospital in 1828. 

Sargent says of it : Fractures of the clavicles, treated by this appa- 
ratus, are daily dismissed from the Pennsylvania Hospital, and by sur- 
geons in private practice, cured without perceptible deformity." 

Norris, in a note to Listorfs Practical Surgery , affirms that " the chief 
indications in the treatment of fracture of the clavicle are perfectly ful- 
filled by the use of this apparatus." 

H. H. Smith, in his Minor Surgery, declares that Fox's apparatus 
accomplishes "perfect cures" in very many cases, and that it is " a very 
rare thing for a simple case to go out of the house (Pennsylvania Hos- 
pital) with any other deformity save that which time cures, viz., the 
deposition of the provisional callus." He has also repeated substantially 
the same opinion in his larger work, entitled Practice of Surgery. 

Such testimony in favor of any dressing demands respectful attention ; 
and I shall not be regarded as detracting from the respect due to these 
authorities, when I express my belief that it is in deference to the dis- 
tinguished reputation of the surgeons who had during the preceding 
thirty years had charge of the services in that hospital, and who have 
been so loud in its praise, that the use of this apparatus has, with us, 
become so general. I must be permitted, however, to express a doubt 
whether it has made deformities of the clavicle " the exception, instead 
of the rule," with us. I have used this dressing in the early years of 
my practice, quite often, but my success has by no means been so flat- 
tering as has been the success of these gentlemen. I have seen others 
employ it, also, and with pretty much the same result. 



• Thomas E. Satterthwaite, M.D., Medical Record, Sept. 27, 1879. 

2 Stephen Smith, New York Journ. Med., vol. ii. 3d series, p. 384 (May, 1857). 

3 Bartlett, my "Report on Defor.," etc., Appendix; also, Bost. Med. and Surg. 
Journ., vol. Ii. p. 404. For illustration, see first edition. 

4 Levis, H. H. Smith's Practice of Surg., p. 365. Am. Journ. Med. Sci., April, 
1860, p. 428. 

5 Dugas, Report on Surgery. 



FRACTURES OF THE CLAVICLE. 



215 



Fig. 54. 




George Fox's apparatus. 



Fox's apparatus consists of a sling, made of muslin cloth ; a wedge- 
shaped axillary pad, made of muslin, also, stuffed, and half the length 
of the humerus ; and of a stuffed collar. 
The axillary pad is not so thick or firm 
as Desault's pad, and for that reason is 
not likely to do harm. It is placed with 
its thickest end upwards, in the axilla cor- 
responding to the broken clavicle, and 
secured in place by tapes attached to its 
upper end, and made fast to the stuffed 
collar upon the opposite shoulder. The 
sling is, in like manner, suspended from 
the stuffed collar. Finally, the hand is 
suspended over the front of the chest by 
a piece of muslin, looped under the wrist, 
and tied around the neck. No bandage 
is employed to confine the elbow to the 
body, and no effort is therefore made to 
convert the arm into a lever, and thus 
force the shoulder out. 

It will be understood that I am speaking 
of this dressing as it was employed some 
years ago, and when the gentlemen whom 
I have quoted spoke of it so approvingly. 
Since then it may have undergone many modifications, or it may have 
been laid aside altogether. 

It must be apparent to every practical surgeon that this apparatus 
could not answer " perfectly" all the indications of treatment, namely, 
to carry the shoulder up, out, and back, so that the clavicle would be 
made to unite without shortening or deformity. 

If, however, the writers intend only to say that no very serious, or 
very marked deformity usually ensues upon the plan of treatment, and 
in some cases none at all, then it will be proper to reply, that this 
amount of success may be attained by almost any form of dressing. It 
has been attained by myself with my own dressing, and with the dress- 
ing recommended by others. 

It will be further necessary to say that the absence or presence of a 
striking deformity, will depend very much upon the age of the patient, 
the character of the fracture — whether more or less oblique — upon the 
point at which the bone is broken, and upon the condition of the patient. 
It will be generally more marked, other things being equal, in thin or 
muscular persons, than in those who are fat and of small and feeble 
muscle. If the overlapping of the fragments is in the plane of the sur- 
face of the integument, the deformity will be less apparent than if one 
fragment lies in front of the other. 

Finally, while I deprecate incautious assumptions in regard to the 
capabilities of any form of dressing for broken collar-bones, a disposi- 
tion to which is manifested by more than one advocate of special plans, 
I am ready to declare my preference for an apparatus consisting essen- 
tially of a sling, axillary pad, and bandages to secure the arm to the 



216 FRACTURES OF THE CLAVICLE. 

chest. Among the considerable variety of dressings which I have used, 
this has seemed to me most simple in its construction, the most comfort- 
able to the patient, the least liable to derangement (if I except Velpeau's 
dextrin bandage, and certain other forms of "immovable" dressings), 
and as capable as any other of answering the, several indications pro- 
posed, while the patient is permitted to walk about. 

No apparatus is better able to answer the first indication, namely, to 
" carry the shoulder up," than the sling. Indeed, in nearly all the 
forms of dressing hitherto devised, the sling is employed for this pur- 
pose. The bandage carried beneath the elbow is, in effect, a sling. In 
a few instances, men of no practical experience have sought to substi- 
tute an upward pressure in the axilla for the sling ; but it is scarcly 
necessary to declare the absurdity of this practice, inasmuch as no pa- 
tient will be found willing to submit to it beyond a few hours. 

It is proper to say, however, that some surgeons, whose opinions are 
entitled to respect, believe that it is quite as important to depress the 
sternal fragment as it is to elevate the acromial, the outer end of the 
sternal fragment being lifted, more or less, by the action of the sterno- 
cleido-mastoid muscle. No doubt this is one of the difficulties with which 
we have to contend in our efforts to restore the two fragments to the 
original line of the axis of the bone. 

But then the elevation of the sternal fragment is only slight in any 
case. The rhomboid ligament quickly arrests its displacement in this 
direction, so that the marked projection of the outer end of this frag- 
ment is due rather to the depression of the outer fragments than to an 
elevation of the inner. 

Inclination of the head to the side of the fractured limb will allow 
the sternal fragment to fall ; but it is impossible for the patient to main- 
tain this position for any length of time. A compress laid over the 
sternal fragment, and held in place by adhesive straps or bandages, will 
be found totally inefficient. Dr. Moore has adopted a more ingenious 
and philosophical method, by calling into requisition the clavicular fibres 
of the pectoralis major to antagonize the sterno-cleido-mastoid. Indeed, 
this is one of the essential principles upon which he rests the superior 
claims of his dressing ; and I have myself observed that when, in the 
case of a recent fracture, the elbow is thrust behind the body, the outer 
end of the sternal fragment is depressed. Nevertheless, I have certain 
theoretical and practical objections to the doctrine as taught so ingeni- 
ously by Dr. Moore. My theoretical objection is that the clavicular 
fibres of the pectoralis major will soon, under the continual strain, be- 
come relaxed, and after a little time cease to accomplish what they did 
at first. This is a law in regard to the action of muscles put upon 
the strain, as every surgeon knows. It may be supposed that, if the 
pectoral muscle is thus rendered less competent to depress the fragment, 
the sterno-cleido-mastoid will be rendered, also, less competent to elevate 
the fragment ; but this is not strictly true : the latter operates at right 
angles with the axis of the bone, and to great advantage, while the former 
acts very obliquely, and to a corresponding disadvantage. 

The practical objection which I have to offer is, that the dressings 
required to maintain this position are exceedingly liable to cause excori- 



FRACTURES OF THE CLAVICLE. 217 

ations and to become disarranged, and that in fact this has happened in 
all, or nearly all, of the cases which have been observed by me. More- 
over, whatever cause may be assigned for the failure, the results have 
been no better, so far as overlapping and deformity are concerned, than 
when my own dressings have been used. 

The second indication, namely, " to carry the shoulder back," is cer- 
tainly more difficult of accomplishment than the first, and it is only im- 
perfectly met by my own method, or by any other form of sling dressing. 
Desault taught that when the arm was lifted by the sling, or by any 
mode of pressure beneath the elbow perpendicularly, the shoulder was 
necessarily carried back. This is probably true, but its effect is not 
very marked. The ordinary figure of 8, which might at first be sup- 
posed to be the most rational mode of effecting this purpose, has long 
since been proven to be a failure. None of the contrivances to hold 
the shoulders back by bands which traverse the axilla, made fast to back 
splints, have done any better. They all cause excoriations, and soon 
become intolerable. Dr. Sayre's adhesive plaster band, attached to the 
upper part of the humerus, below the axillary margin, either loosens or 
excoriates, also, and in the end proves inefficient. 

After all it must be said, that the indication " to carry the shoulder 
back," except so far as it incidentally accomplishes the indication " to 
carry the shoulders out," and thus obviate the overlapping of the frag- 
ments, is relatively unimportant. It is seldom that the falling forwards 
of the shoulders is very marked, or in itself a source of deformity; but 
carrying the shoulder back does diminish or overcome the riding of the 
fragments, and in this view alone is it important, and for this reason, 
surgery will be indebted to any one who devises a method by which this 
position of the shoulder can be maintained until the union of the frag- 
ments is consummated. 

The third indication is " to carry the shoulder out," by which means 
it is proposed to overcome, directly, the riding of the fragments. We 
have seen that this may be accomplished, indirectly, by carrying the 
shoulder back ; but, unfortunately, no means has yet been found by 
which this can be done and permanently maintained, while the patient is 
in the erect or sitting posture. 

The thick axillary pad, and all other devices by which it is proposed 
to act upon the humerus as a lever, and thus force the shoulder out, 
have totally failed or proved eminently mischievous. In short, I may 
say that this indication can, in my opinion, be effectually accomplished 
in only one way, and that is, by laying the patient upon his back on a 
flat, firm mattress, and thus pressing the base and inferior angle of the 
scapula strongly and steadily against the back. The requisite pressure 
upon the scapula cannot be maintained by any plan yet contrived while 
the patient is in the sitting or standing posture, and especially when per- 
mitted to walk about. We shall be warranted therefore in attempting 
to accomplish this indication fully in only rare and exceptional cases. 
If a slight overlapping and deformity were to cause any appreciable 
diminution of the strength or usefulness of the arm, patients might pro- 
perly enough be subjected to such restraints for a few weeks; but expe- 
rience has shown that such displacements do not, in any degree, maim 
15 



218 



FKACTURES OF THE CLAVICLE 



Fig. 55. 



the arm. Whether in the case of women, in examples of unusual dis- 
placement, the clanger of disfigurement would warrant a resort to this 
method, must be left to the judgment of the surgeon and the choice of 
the patient ; but in adopting what may be termed the " posture" treat- 
ment, it will be advisable, also to employ the sling, pad, and bandages 
in the manner hereafter to be described. 

The mode of dressing a fractured clavicle which, while the patient is 
at liberty to walk about, will secure the best results with the least suffer- 
ing and annoyance, is as follows : — 

The arm hanging perpendicularly beside the body, a sling is placed 
under the elbow and forearm, and tied over the opposite shoulder. An 

axillary pad, composed of cotton bat- 
ting inclosed in a cloth cover, is placed 
well up in the axilla, and the elbow is 
then secured firmly to the side of the 
body with several turns of a roller. 

Dr. Coates, in the excellent paper 
already referred to, calls attention to 
the danger of making too much pressure 
upon the brachial artery and nerves, 
when the axillary pad is used, and the 
arm is, at the same time, carried for- 
wards upon the body. In bringing the 
elbow forwards, so as to lay the fore- 
arm across the body, the humerus is 
made to rotate inwards, and the brachial 
artery and nerves are brought into 
more direct apposition with the pad ;* 
Avhile in the position which I have 
recommended and practised hitherto, 
these nerves and vessels are removed 
in a great measure, but not entirely, 
from pressure. 

The pad should be no thicker than 
is necessary to fill completely the axillary space, its purpose being to 
steady the arm, and, in some slight degree, to counteract the action of 
those muscles which tend to displace the shoulder inwards. It should 
be long enough in its antero-posterior diameter to project distinctly in 
front and behind, otherwise it will not keep its place. In the adult it 
needs to be six or seven inches long. In the direction of the axis of the 
limb, its length should be less, perhaps four inches. Being now well 
pressed up into the axilla, and secured with a needle and thread to the 
upper edge of the roller which encircles the lower part of the arm and 
the body, it will keep its position and serve some useful purpose. 

The sling may be made of cotton or flannel cloth, and suspended from 
the opposite shoulder by the aid of four tapes, a broad and thick pad of 
folded cloth being laid upon the shoulder to support the knots. A con- 
siderable experience has satisfied me that the stuffed collar, used in the 




The author's dressing for fractured clavicle. 



1 Coates, Am. Journ. Med. Sci., vol. xviii. p. 62. 



FRACTURES OF THE CLAVICLE. 219 

Fox dressing, possesses no advantage as a means of suspension. The 
leather sling, also, in use at some hospitals, is liable to the objection that 
it cannot be stitched to the roller, which encircles the body and lower 
part of the arm, in the manner I shall hereafter describe. 

The roller should be made to encircle the lower fourth of the arm, and 
a few turns should pass beneath the forearm as far forwards as the hand, 
in this manner securely fixing the elbow and forearm against the side 
and front of the body. 

If thought necessary, the hand may be supported by a loop of bandage 
passed under the wrist and tied over the neck. 

Finally, in order that this dressing may retain its place and serve 
its purpose most effectually, its several parts should be stitched together 
thoroughly wherever the dressings cross or approach each other. In 
no other way can anything like permanency be insured in a portion of 
the body so movable as the shoulder and chest ; but even with this 
precaution, daily attention and occasional readjustment are generally 
required. 

Treatment of Incomplete Fractures of the Clavicle.- — -In case of par- 
tial fracture of the clavicle, accompanied with a persistent bend in the 
line of the axis of the bone, it is proper to attempt the replacement of 
the fragments by direct pressure. The ends of the bone being fixed, we 
cannot, as in the case of a partial fracture of other long bones, employ 
leverage ; and with direct pressure alone, applied in a degree which 
might be regarded as incurring no danger of causing a complete frac- 
ture or of a dislocation, our chances of success are very small. I can- 
not say that I have ever succeeded in accomplishing anything in this 
way, although I have often made the attempt, and would always advise 
others to do the same. A failure, however, to restore completely the 
line of the. axis of the bone is not, I imagine, a matter of great conse- 
quence, since, as has already been fully explained when speaking of 
partial fractures in general, the natural form will be in most, if not in 
all cases, completely restored after the lapse of a few months or years. 
This observation applies especially to partial fractures occurring in 
childhood and infancy. I have no experience as to what is the result 
of a similar deformity left after a partial fracture in the adult. 

As to the method of dressing these fractures, it need not differ from 
that recommended for complete fractures ; but in a majority of these 
cases I have thought it sufficient to place the arm in a sling, with a 
bandage around the elbow and body to keep the arm at rest, or I have 
directed the mother to make the sleeve fast to the front of the dress 
with tapes, or the hand and arm of the child may be withdrawn from 
the sleeve and placed across the body inside the dress, and secured in 
this position by a belt around the waist. In this case, of course, the 
dress must remain upon the child until the cure is completed. The 
axillary pad can seldom, if ever, serve any useful purpose. 

Union occurs with great rapidity, sometimes as early as the seventh 
or tenth day ; but the arm ought to be kept quiet, as a matter of safety, 
two or three weeks. 

For a more full consideration of the subject of partial fractures of 
the clavicle, the reader is referred to the chapter on " Incomplete 
Fractures." 



220 FRACTURES OF THE SCAPULA 



CHAPTER XX. 

FRACTUBES OF THE SCAPULA. 

Fractures of the scapula may "be divided into those which occur 
through the body, the neck, the acromion process, and the coracoid. 

§ 1. Fractures of the Body of the Scapula. 

Under this title I propose to consider not only fractures of the 
" body," properly speaking, but also fractures of the angles and of the 
spine. 

Causes. — The scapula is usually broken by the fall of some heavy 
body directly upon the bone, or by some severe crushing accident, by 
the kick of a horse, by a fall upon the back ; in short, by direct causes 
alone, and by such causes as operate with great violence. 

Malgaigne says that a Doctor Heylen has recently published a case 
of this fracture which he believes to have been the result of muscular 
action, occurring in a man forty-nine years old. The case, however, is 
not stated so clearly as to relieve us entirely of a doubt as to the nature 
and cause of the accident: 

I have myself recorded six cases which have been under my treat- 
ment ; and I have seen a few other examples of fractures of the body of 
the scapula not caused by firearms. There are two cabinet specimens of 
fracture of the body of the scapula below the spine in the Pennsylvania 
Medical College, and two involving the spine. Dr. Mutter had in his 
collection a fracture of the posterior angle, and Dr. March had a 
specimen of fracture of the body. I believe also that in the collection 
of the late Dr. Charles Gibson, of Richmond, there were one or two 
specimens of this fracture. I know of no other museum specimens in 
this country except my own of partial fracture, described in the chapter 
on Partial Fractures. 

Ravaton, after a practice of fifty years, declared that he had never 
seen a fracture of the scapula except as it had been produced by fire- 
arms. Among 2358 fractures reported from Hotel Dieu during a period 
of twelve years, only four examples of fracture of the scapula are re- 
corded ; and, at Middlesex Hospital, Lonsdale has noticed, among 1901 
fractures, only eight of the body of the scapula. 

The infrequency of this fracture is no doubt due in a great measure 
to the elasticity of the ribs, to the mobility of the scapula, and to the 
softness of the muscular cushion upon which it reposes. 

Symptoms. — Since this bone is seldom broken except by great force 
directly applied, the usual signs of fractures are likely to be concealed 
by the speedy occurrence of swelling. It is for this reason that it be- 
comes necessary, generally, that the examination should be made with 



FKACTURES OF THE BODY OF THE SCAPULA 



221 



great care before we can safely determine upon the diagnosis. I have 
more than once had occasion to correct the diagnosis of other practi- 
tioners, who believed they had discovered a fracture of the scapula. 

When, however, the line of the fracture has traversed the spine, and 
any considerable displacement has occurred, one may recognize the 
fracture easily by merely Fig 56 

carrying the finger along the 
crest. 

If the fracture has occur- 
red through the body, below 
or above the spine, or through 
either of the angles, the dis- 
placement may not be so 
easily recognized. The sur- 
geon ought then to trace 
carefully with his finger the 
outlines of the scapula ; and 
this he will be able to do 
more satisfactorily if he 
places the scapula in such 
positions as elevate its mar- 
gins and render them more 
prominent. In examining 
the posterior angle, the hand 
of the injured limb may be 
placed upon the opposite 
shoulder, the forearm being 
carried across the front of 
the chest ; but in searching 
for a fracture below the 
spine, the forearm ought to 
be laid across the back. 

Crepitus, which is not always present owing to the fact that the frag- 
ments overlap completely, or because they have been widely separated 
by the action of the muscles, may generally be detected by placing the 
palm of the hand upon some portion of the scapula, so as to steady the 
fragment upon which it rests, while the arm is moved backwards and 
forwards, and in various other directions, until their broken surfaces are 
brought into contact. 

Some degree of embarrassment in the motions of the shoulder and 
arm must always result from this fracture ; sometimes this embarrass- 
ment is very great, but it ought not to be considered ever as diagnostic 
of a fracture, since it may be produced equally by a severe contusion ; 
and even when it is accompanied with a fracture, it is due rather to the 
contusion than to the fracture. 

Pathology, Seat, Direction, etc. — Of incomplete fractures of the 
scapula, I have already mentioned that I have seen one example. 

Malgaigne thinks that he has seen one case of incomplete fracture, 
which occurred in a man who was injured by the fall of a heavy block 




Fracture of the posterior angle of scapula, with fissure. 
Mutter's collection, Specimen C, No. 187. 



222 FRACTURES OF THE SCAPULA. 

of stone upon his back ; but as the patient recovered, his diagnosis must 
remain doubtful. I know of no other recorded examples. 

Complete fractures occur most often below the spine, and they are 
generally oblique or transverse, sometimes nearly longitudinal. 

Fractures involving the spine are noticed occasionally ; but I am not 
aware that any one has ever seen a specimen of a fracture of the spine 
alone, although many surgeons have spoken of them. 

I have mentioned one example of a fracture of the posterior angle as 
being in the cabinet of Dr. Mutter, of Philadelphia. Malgaigne seems 
to doubt its existence, but speaks of it as a fracture which surgeons 
have " imagined." 

Occasionally the bone is broken into more than two fragments. 

As a result of the fracture there is usually more or less displacement ; 
generally, if the fracture is below the spine and transverse, and espe- 
cially if its direction is oblique from before backwards and downwards, 
the inferior fragment is displaced forwards, or forwards and upwards, by 
the action of the serratus major anticus, or of the teres major, while 
the superior fragment is inclined to fall backwards, and sometimes it is 
carried upwards and backwards, following the action of the rhomboideus 
major. 

In cases of comminuted fractures, and occasionally in simple fractures, 
the direction of the displacement is reversed, or altogether changed, so 
that the lower fragment, instead of being in front, is behind the upper 
fragment ; and instead of overlapping, the two fragments are more or 
less drawn asunder. These are deviations which are not easily ex- 
plained, but which depend, perhaps, rather upon the direction of the 
blow than upon the action of the muscles. 

In a few cases there is no displacement in any direction, although 
the crepitus and mobility sufficiently demonstrate the existence of a 
fracture. 

Prognosis. — If displacement actually has taken place, it will be found 
very difficult, as we shall see when we come to consider the treatment, 
to hold the fragments in apposition until a cure is completed ; so that 
they are pretty certain to unite with a degree of overlapping, or other 
irregularity. 

Lonsdale, Lizars, Chelius, Nekton, Gibson, Malgaigne, and others 
have spoken of the difficulty or impossibility generally of keeping these 
fragments in place. Nelaton and Malgaigne, indeed, confess that they 
have never succeeded ; Gibson declares that it is scarcely possible ; 
while Chelius affirms that if the fracture is near the angle, the cure is 
always effected with some deformity. 

But then it is not probable that the patient will ever suffer any seri- 
ous inconvenience from this irregular union of the fragments, since the 
perfection of its function depends less upon any given form or size than 
in the case of almost any other large bone ; and if, as has been observed 
by Lonsdale, the free use of the arm is not recovered for some time, or 
if, as has been noticed by B. Bell, a permanent stiffness results, these 
should be regarded as due to the injury which those muscles have 
suffered which envelop the scapula, or to some injury of the ligaments 
and muscles which surround the shoulder-joint. 



FRACTURES OF THE BODY OF THE SCAPULA. 223 

In some few examples upon record, the bone has been so comminuted, 
and the soft parts adjacent so much injured, that suppuration and necro- 
sis have ensued. And in one case of gunshot fracture of the scapula, 
resulting in necrosis, I have had occasion to remove the entire scapula. 1 

The case referred to is briefly as follows : Private Wm. Murphy, 73d 
Regt. N. Y. Vol., set. 33, was admitted to my service, Bellevue Hos- 
pital, February, 1866. He stated that he was wounded at Fredericks- 
burg December 13, 1862, by grape-shot, which fractured both the scap- 
ula and head of the humerus. Six days later the head and a portion of 
the shaft of the humerus were removed. At a later period necrosis 
attacked the scapula, and I removed the entire scapula, including the 
acromion and coracoid processes, at Bellevue February 10, 1866, in the 
public amphitheatre. Subsequently the patient and the removed scap- 
ula were brought before the New York Pathological Society. At this 
time he had recovered very good use of the limb, and was able to con- 
tract effectively the biceps and coraco-brachialis, although their upper 
points of attachment were only cicatricial tissue. Murphy received a 
pension, and is subsequently reported by the pension officers as having a 
large cicatrix over the site of the scapula, the wound made by the resec- 
tion having healed completely within a few months after the operation. 
They report, also, some points of bone, which must have been reproduc- 
tions. The arm was atrophied, and of little value. He died June 24, 
1871, having survived the operation more than eight years. Dr. Otis, 
compiler of the Surgical History of the War of the Rebellion, who has 
gathered a complete account of this case, remarks that " it affords per- 
haps a solitary example of a successful extirpation, for the results of 
shot injury, of the scapula, with preservation of the upper extremity." 

Treatment. — In the treatment of this fracture, the first object with all 
surgeons has been to restore the fragments to place, and this they have 
chiefly sought to accomplish by position ; after which they have en- 
deavored to immobilize the fragments by bandages, etc. 

In seeking to accomplish the first indication, they have placed the 
shoulder and arm in a great variety of postures. Nearly all seem to 
have regarded it as of some importance that the shoulder should be 
elevated, so as to relax the muscles attached to the upper and back part 
of the scapula, and thus permit the upper fragment to fall downwards 
and forwards. 

If we confine our remarks first to fractures through the body, and do 
not include fractures of the inferior angle, this indication is the only 
one which Nelaton and Mayor have sought to accomplish, and for this 
purpose they employ a simple sling ; while Amesbury, Liston, Lons- 
dale, S. Cooper, South, Skey, Miller, Pirrie, have added to the sling a 
bandage or roller, which is made to inclose snugly the body and arm. 

Erichsen uses the body bandage alone, as in fractures of the ribs, 
while B. Cooper, Lizars, and Tavernier employ a bandage which in- 
closes not only the body, but also the arm ; neither of these last-men- 

1 Surgical History of the War of the Rebellion, vol. ii., Washington, 1876, pp. 
492, 494, 498, 499, 500. Proceedings of N. Y. Patholog. Soc, 1866, in Med. and Surg. 
Reporter, vol. xiv. p. 372. 



224 FRACTURES OF THE SCAPULA. 

tioned surgeons recommends a sling, or any other means to elevate the 
arm. 

Johannes de Gorter advises that a sling shall be used, but that the 
elbow shall be lifted away from the side of the body, so as to relax the 
deltoid. Chelius and Desault recommend the same position, but with 
the addition of an axillary pad, whose apex shall be directed upwards, 
secured in place with appropriate bandages. 

Pierre d'Argelata used also an axillary pad, but instead of a wedge 
he recommended a simple roll ; and instead of lifting the elbow away 
from the body, he directed that the elbow should be secured against the 
side, making use of the axillary roll as a fulcrum. 

Petit and Heister advised that the elbow and forearm should be car- 
ried forwards upon the front of the chest, and secured in this position. 

In the treatment of no other fracture perhaps have surgeons differed 
more widely as to the indications than in this, since, as we have seen, 
some recommend the elbow to be carried from the body, and some that 
it shall be made to approach the body ; one directs that the elbow shall 
fall perpendicularly beside the chest, a second prefers that it shall be 
carried a little back, and a third that it shall be brought well forwards. 
In one thing alone have they nearly all agreed, namely, that the elbow 
shall be lifted ; and generally also it has been recommended that the arm, 
forearm, and body shall be confined by sufficient bandages to insure 
quietude. It might be proper to conclude, therefore, that the sling and 
bandage constitute all of the apparatus which is necessary or useful ; 
and that it is relatively unimportant whether the elbow is near or remote 
from the body, or whether it is in front of, or behind, or beside the chest. 

Such, indeed, is the conclusion to which we have ourselves arrived ; 
yet if, in relation to the position of the elbow, a choice were to be ex- 
pressed, w T e w T ould give the preference to that in which the arm is laid 
vertically beside the body, or, perhaps, with the elbow a little inclined 
backwards, so as to relax as completely as possible the teres major. 

It is quite probable, however, that no single position will be found of 
universal application ; and perhaps it would be more safe to advise the 
surgeon in any given case first to reduce the fragments as completely as 
possible by manipulation, and then to place the arm in such a position 
as, upon careful experiment in this particular instance, he shall find 
enables him to best retain them in place. 

If, however, the fracture is such as to have separated the inferior 
angle from the body, it will be well to follow the advice of Boyer and 
of others, and to place a compress in front of the inferior angle, to resist 
the greater tendency to displacement in this direction. This compress 
will more effectually accomplish this indication if the roller with which 
it is secured to the body, and with which we seek to immobilize the 
scapula and chest, is turned from before backwards, or in a direction of 
antagonism to the action of the muscles which produce the displacement. 

Desault, with Chelius and Bransby Cooper, has recommended also, in 
the case of a fracture through the angle, that the forearm should be acutely 
flexed upon the arm, and that the hand should be placed in front of the 
chest, upon the sound shoulder, a position which is always irksome, and 



FRACTURES OF THE NECK OF THE SCAPULA. 



225 



sometimes insupportable, and which does not offer in any ease sufficient 
advantages to render it worthy of a trial. 

§ 2. Fractures of the Neck of the Scapula. 

If by the "neck" of the scapula surgeons mean that slightly con- 
stricted portion of this bone which is situated at the base of the glenoid 
cavity — and it is to this portion, we believe, that anatomists have gene- 
rally applied the term "neck" (we will take the liberty of calling this 
the "anatomical" neck) — 'then its fracture is certainly very rare. In- 
deed, the existence of this fracture, uncomplicated with a comminuted 
fracture of the glenoid cavity, is denied by Sir Astley Cooper, South, 
Erichsen, and others. Mr. South says there is' no such specimen in any 
of the museums in London ; and I have not been able to find one in any 
of the American cabinets. Dr. Valentine Mott has said to me that he 
had never seen a specimen, and that in the natural condition of the bone 
he regards its occurrence as impossible. Such, I confess, also, is my own 
conviction. 

If, however, it is intended, in speaking of fractures of the neck of the 
scapula, to refer, as Sir Astley Cooper has done, only to fractures ex- 
tending through the semilunar notch, behind the root of the coracoid 
process ("surgical" neck), then its existence is certain ; yet the fracture 



Fig. 57. 



Fig. 58. 





Comminuted fracture of the glenoid 
cavity. 



Fracture of the neck of the scapula ; according to 
Sir Astley Cooper. 



is not common. Duverney has reported one example, the existence of 
which he established by a dissection. The coracoid process was broken 
at the same time, but the fracture through the surgical neck was distinct 
from this ; and Sir Astley has recorded three examples in which the 
diagnosis was very clearly made out, yet not actually proven by an 
autopsy. 

In Holmes's Surgery it is stated that there is one specimen in the 



226 FRACTURES OF THE SCAPULA. 

museum of Guy's Hospital ; another, in which repair has taken place, 
in the museum of the Royal College of Surgeons ; and the writer refers, 
also, to the case reported by Duverney in 1751. x 

Perhaps some of the cases, diagnosticated during the life of the patient 
as fractures of the neck of the scapula, were fractures of the lower or an- 
terior lip of the glenoid cavity ; but I have never found such a specimen 
in any collection of bones which I have yet examined, and it must be ad- 
mitted to be exceedingly rare. 

Symptoms. — Sir Astley Cooper justly remarks that " the degree of 
deformity produced by a fracture of the surgical neck of the scapula 
depends upon the extent of laceration of a ligament which passes from 
the under part of the spine of the scapula to the glenoid cavity. If this 
be torn" (and to this Ave ought to add the ligaments passing from the 
coracoid process to the clavicle and acromion process — coraco-clavicular 
and coraco-acromial), " the glenoid cavity and the head of the os humeri 
fall deeply into the axilla, but the displacement is much less if this re- 
mains whole." 

The usual signs are, a depression under the acromion process, the 
same as in dislocation of the head of the humerus downwards, but not 
so deep ; the head of the humerus felt, perhaps, in the axilla ; crepitus, 
and the immediate recurrence of the displacement whenever, after the 
reduction has been fairly accomplished, the arm is left unsupported. 
The crepitus is best discovered by resting one hand upon the top of the 
shoulder in such a manner as that a finger shall touch the point of the 
process, while the arm is rotated and moved up and down by the oppo- 
site hand. It may also be easily ascertained that the coracoid process 
moves with the humerus instead of the scapula. Occasionally the 
accident is accompanied with paralysis of the arm, from pressure upon 
the axillary nerves ; and a rupture of the axillary artery is also men- 
tioned by Dugas. 2 

Treatment. — The indications of treatment are three, namely, to carry 
the head of the humerus, with the glenoid cavity, etc., up, to carry it 
out, and to confine the body of the scapula. The first is accomplished 
by a sling, the second by a pad in the axilla, and the third by a broad 
roller carried repeatedly around the arm and chest and across the shoul- 
der. In short, the treatment is essentially the same as that which we 
have recommended for a broken clavicle. 

§ 3. Fractures of the Acromion Process. 

Examples of fracture of the acromion process have been reported by 
Duverney, Bichat, Avrard, A. Cooper, Desault, Sanson, Nelaton, Mal- 
gaigne, West, 3 Brainard, 4 Stephen Smith, and others. I have myself 
seen five cases. 

In the case seen by Cooper it entered the articulation of the clavicle, 

1 Holmes's Surgery, vol. ii. p. 776, Araer. ed., 1870. 

2 Remarks on Frac. of Scapula, by L. A. Dugas, Georgia. 
Jan. 1858. 

8 West, Penin. Journ. of Med., vol. v. p. 254. 

4 Brainard, Bost. Med. and Surg. Journ., vol. xxxi. p. 501. 



FRACTURES OF THE ACROMION" PROCESS. 227 

and produced at the same moment a dislocation. Malgaigne says it 
occurs generally farther up, and posterior to the attachments of the 
clavicle, "near the junction of the diaphysis with the epiphysis," and 
that the fracture is in most cases transverse and vertical ; but Nelaton 
saw a case in which the fracture was oblique. In the case reported by 
C. West, of Hagerstown, Md., the fracture was through the base of the 
process. In two of the examples seen by me the fracture was in front 
of the clavicle ; in the third, occasioned by the fall of a barrel of flour 
upon the shoulder, the fracture occurred at the acromio-clavicular articu- 
lation, and was accompanied with an upward dislocation of the outer end 
of the clavicle ; in the fourth the fracture occurred at the same point, 
but there was neither displacement of the clavicle nor of the process, the 
fracture being only recognized by the crepitus and motion. The fifth, 
a man set. 31, was brought to my notice by Dr. Thomas J. Sabine, sur- 
geon to Bellevue Hospital, Oct. 23, 1876. The patient had been struck 
by a policeman's club. There was distinct crepitus, the fracture being 
posterior to the acromio-clavicular junction, but there was no displace- 
ment of the fragments or of the clavicle. 

There is some reason to believe, I think, that a true fracture of the 
acromion process is much more rare than surgeons have supposed, and 
that in a considerable number of the cases reported there was merely a 
separation of the epiphysis ; the bony union having never been com- 
pleted. If such fractures or separations occurred only in children very 
little doubt might remain as to the general character of the accident ; 
but the specimens which I have found in the museums, and the cases 
reported in the books, have been mostly from adults. It is more diffi- 
cult, therefore, to suppose these to be examples of separation of epiphy- 
ses, but I am inclined to think that in a majority of instances such has 
been the fact. It is very probable, also, that in the case of many of the 
specimens found in the museums, called fractures, the histories of which 
are unknown, they were united originally by cartilage, and that in the 
process of boiling, or of maceration, the disjunction has been completed. 
The narrow crest of elevated bone which frequently surrounds the pro- 
cess at the point of separation, and which Malgaigne may have mistaken 
for callus, is found upon very many examples of undoubted epiphyseal 
separations which I have examined ; and this circumstance, no doubt, 
has tended to strengthen the suspicion that these were cases of fracture. 

This opinion is confirmed by the remark of Mr. Fergusson that a frac- 
ture of this process is an accident " of rare occurrence." " I have dis- 
sected," he adds, " a number of examples of apparent fracture of the end 
of this process ; but in such instances it is doubtful if the movable portion 
had ever been fixed to the rest of the bone." Dr. Jackson, in a letter to 
me, says there are four specimens in the museum of the Massachusetts 
Medical College, and in the museum of the Boston Society for Medical 
Improvement, which might easily be mistaken for fractures, but which 
only illustrate to how late a period the bony union is sometimes delayed. 
In one specimen the patient could not have been less than forty years of 
age ; " the acromial process of each scapula was fully formed, but having 
no bony union whatever with the bone itself. The union was ligamen- 
tous, but strong and close." 



228 



FBACTUKES OF THE SCAPULA 



To the same class belong several specimens in my own collection ; 
specimens 163 and 99T in Dr. March's collection at Albany ; TOT in the 
Albany College collection ; two specimens in the Mutter, and one in the 
Jefferson Medical College museums. 

I wish to mention, also, that in the case of my own specimens of epi- 
physeal separation, as well as most of the specimens which I have 
examined, the ends of the fragments were closed Avith a compact bony 
tissue. 

The mode of development of the scapula will explain these cases. The 
scapula is formed from seven centres ; namely, one for the body, one for 
its posterior border, one for its inferior border, two for the acromion 
process, and two for the coracoid. Ossification of the body exists to a 
certain extent at or near the period of birth. It commences in one of 

Fig. 59. 




Scapula, with epiphyses. (From Gray.) 



the centres of the coracoid process, about one year after birth, and unites 
to the body at about the fifteenth year. All the other centres remain 
cartilaginous until from the fifteenth to the seventeenth year, when 
ossification commences, and is completed by a common union among all 
parts, usually between the twenty-second and twenty -fifth years. 

No doubt, however, a fracture of this process does occasionally take 
place. In addition to my own, I have already mentioned several other 



FRACTURES OF THE ACROMION PROCESS. 229 

examples, some of which have been confirmed by dissection, and in the 
case mentioned by Stephen Smith, an autopsy, made three weeks after 
the accident, showed a fracture in front of the clavicle without displace- 
ment, the periosteum covering its upper surface not being torn ; the 
fragment could be turned back as upon a hinge. 

Prognosis when the Fracture is in front of the Clavicle. — The pro- 
cess generally unites with a slight downward displacement. This oc- 
curs in the two examples seen by me ; but in such cases the motions of 
the arm are not in consequence much, if at all, impaired ; unless, indeed, 
it is so much depressed as to interfere with the upward movements of 
the arm ; a result which Heister erroneously supposed was inevitable. 

Sir Astley Cooper says that a true bony union is rare in these frac- 
tures, and that there generally results a false joint, the fragments uniting 
by a fibrous tissue ; but sometimes the surfaces, instead of uniting either 
by bone or ligament, become polished, and even eburnated. 

Malgaigne has noticed, also, in a specimen contained in the Dupuy- 
tren museum, a hypertrophy of the lower fragment, this portion having 
a diameter nearly twice as great as that of the portion from which it 
was detached. 

Prognosis ivhen the Fracture is through the Articulation of the 
Clavicle.- — -Where neither the fragments nor the clavicle are displaced, 
the prognosis ought to be favorable : but in case the clavicle is dislocated, 
there will be encountered the same difficulties as in the case of simple 
acromial dislocation of the clavicle, or even more serious difficulty, and 
I do not see how it can be expected that a perfect reduction should be 
maintained. 

Prognosis when the Fracture is Posterior to the Articulation of the 
Clavicle. — In these cases, if there is little or no displacement, the prog- 
nosis is favorable ; but if the fragments are displaced, a perfect adjust- 
ment may be difficult. 

Symptoms. — Where no displacement exists, the diagnosis must always 
be difficult, if not impossible. In such a case we could only be instructed 
by the manner in which the injury had been received, by the contusion, 
and by the presence of mobility or crepitus. 

In examples attended with displacement, if no swelling is present, the 
finger carried along the spine of the scapula to its extremity, will easily 
detect the fracture by the abrupt termination or elevation of the process, 
or by the presence of a fissure, or a depression; but as to the other 
symptoms, they must depend very much upon the point at which the 
fracture has taken place. If in front of the acromio-clavicular articula- 
tion, the position of the arm in its relations to the body will not be 
changed ; but if the fracture is through the articulation, and a disloca- 
tion of the clavicle results, or if it is behind the acromio-clavicular 
articulation, the arm, having in either case lost the support of the clavi- 
cle, will be inclined to assume the same position that it does in a 
fracture of the clavicle ; that is, the shoulder will be disposed to fall 
downwards, inwards, and forwards. 

Treatment. — If the fracture has taken place in front of the acromio- 
clavicular articulation, no doubt the most rational plan of treatment, if 
one aims at the accomplishment of a perfect bony union, is that recom- 



230 FRACTURES OF THE SCAPULA. 

mended by Delpech ; that is, placing the patient in bed, upon his back, 
and carrying the arm out from the body nearly to a right angle ; since 
by this method the. fragment is not only lifted, but the deltoid muscle is 
relaxed, and, consequently, the fragment is no. longer forcibly drawn 
away from the spine of the scapula. If, therefore, the patient will sub- 
mit to this treatment for a sufficient length of time, the union must be 
accomplished with the least possible amount of displacement. But in 
the case of a fracture of the acromion process at the point indicated, 
only a few fibres of the deltoid muscle are attached to the fragment 
which has been broken off, and consequently, even in case no union took 
place, the muscular power of the arm could not be appreciably impaired. 
Nor would a slight falling or depression of the fragment cause any em- 
barrassment to the motions of the shoulder-joint. 

For these reasons it is scarcely worth while to do anything more, in a 
great majority of cases, than to place in the axilla a pretty heavy 
wedge-shaped pad, with its apex upwards, and then secure the arm to 
the side with a sling and roller, the same as in the case of a fracture of 
the clavicle. 

If, however, the fracture has taken place at or behind the junction of 
the c avicle with the process, the indications of treatment will be, in all 
respects, the same as in the case of a fracture of the clavicle. 

§ 4. Fractures of the Coracoid Process. 

" The coracoid process," says Mr. Lizars, " is said to be broken off, 
but this I question very much ; it must be along with the glenoid cavity, 
or there must be a fracture of the neck of the scapula." 

Dr. Neill, of Philadelphia, has in his cabinet a specimen of separation 
of this process at about one inch from its extremity. The line of sepa- 
ration is somewhat irregular ; there is no callus, but it is united to the 
upper portion by a dried tissue, half an inch in length, and continuous 
with the periosteum. This has been regarded as an example of fracture; 
but although the scapula is large, and evidently belongs to an adult, the 
fact that the acromion process is not yet united by bone renders it 
probable that this, also, is an epiphyseal separation. Prof. Charles 
Gibson, of Richmond, Va., has informed me also that he has in his 
cabinet a dried specimen, from an adult, which has been broken ob- 
liquely near the end, but which is now united by a ligamentous or 
fibrous tissue of one line and a half in length. The fragment is dis- 
placed a little forwards as well as downwards. Reuben D. Mussey, of 
Cincinnati, possessed a very remarkable and conclusive example of this 
fracture. The humerus is dislocated forwards, the head and neck being 
firmly united to the neck and venter of the scapula, while at the same 
time the coracoid process is broken and displaced. Dr. Jackson, of 
Boston, says that specimen No. 453 in the museum of the Massachusetts 
Medical College seems clearly to have been a fracture involving the base 
of the coracoid process, and which, having taken place somewhere within 
a year of the death of the person, had become united by bone, and that 
just before death the process had broken off, and so completely, as to 
involve a portion of the glenoid cavity. 1 

'• The author's Report on Deformities, op. cit. 



FRACTURES OF THE CORACOID PROCESS. 



231 



Bransby Cooper relates a case of fracture through the base, which 
after eight weeks, when the patient died, was found to be united by a 
ligament. The acromion process was broken at the same time, and had 
united in the same manner. The head of the humerus was also broken 
and partly united. 1 One example is said to have occurred in the prac- 
tice of Dr. Arnott, at the Middlesex Hospital, London, in consequence 
of which the patient died, when a dissection disclosed the true nature of 
the accident. 2 Mr. South has also reported a case resembling somewhat 
Mussey's, but much more complicated. The humerus was partially dis- 
located forwards, the clavicle, acromion process, and the olecranon were 
broken as well as the coracoid process. Neither the fracture of the 
clavicle nor of the coracoid process was made out until after the patient 
died, which was on the fourth clay ; the fact of the existence of these 
fractures being then ascertained by dissection. 3 Holmes has reported a 
case. 4 Erichsen says there is in the museum of the University College 
a preparation showing a fracture at the base of this process, the line of 
fracture extending across the glenoid cavity. 5 Duverney, Boyer, and 
Malgaigne have also reported four additional examples, confirmed by 
dissections. 6 

The existence of this form of fracture, established by at least nine or 
ten dissections, can no longer be denied ; yet it is often accompanied 
with serious complications, and such 
as have sometimes proved fatal. In 
the only two cases, however, in which 
I have had reason to believe that I 
had to deal with a fracture of this 
kind, the symptoms and termination 
were less grave, although they were 
both complicated with an upward dis- 
location of the outer end of the clavi- 
cle. A gentleman residing in the 
country was struck by a board which 
fell edgewise upon his shoulder. The 
fracture of the coracoid process does 
not seem to have been recognized by 
his surgeon. An apparatus was ap- 
plied to retain the clavicle in its 
place, but after three months, when 
he called upon me, it still remained displaced as at first. During all of 
this time the apparatus had been steadily kept on. On laying off the 
dressing, I discovered that the coracoid process was detached, obeying 
constantly the movements of the head of the humerus, but being not at 
all subject to the movements of the scapula. Some months later I 
examined the arm again, and found the parts in the same condition as 



Fig. 60. 




Fracture of the coracoid process. 



1 B. Cooper, edition of Sir Astley on Frac. and Disloc, Anier. ed., p. 380. 

2 Arnott, Fergusson's Surg., p. 231. 

3 South, Lond. Med.-Chir. Rev., 1S40, vol. xxxii., new series, p. 41. 

4 Holmes, Med.-Chir. Trans., vol. xli. p. 447. 

5 Erichsen, Surgery, p. 207. 6 Malgaigne, op. cit., p. 512. 



232 FRACTURES OF THE SCAPULA. 

before, but the functions of the arm were not impaired. A girl was 
admitted to Bellevue Hospital in November, 1868, having fallen upon 
her left shoulder, and having sustained a complete luxation of the acro- 
mial end of the clavicle, upwards and outwards. Upon careful examina- 
tion, a fracture of the coracoid process was also diagnosticated, indicated 
bj both mobility and crepitus. 

By courtesy of Dr. James L. Little, of this city, I was permitted to 
see, on the 4th of April, 1879, an example of this fracture in the person 
of John Gannon, set. 38. Four days before he had been struck by an 
iron rod upon his shoulder, but at what precise point could not be deter- 
mined. There was no mark over the seat of fracture, and not much sign 
of contusion. The arm, forearm, and hand were completely paralyzed. 
The coracoid process seemed to be displaced inwards, or towards the 
median line of the body; but when the humerus was forcibly rotated 
outwards, the coracoid resumed its place, and if now pressure was made 
upon its extremity, it became again suddenly displaced, with a subdued, 
grating sensation. The presumption appears to be, that the fragment 
was reduced by external rotation of the humerus ; but this position could 
not be maintained on account of the severe pain which it caused. 

Dr. E. C. Huse, of Rockford, 111., has also recently reported a case — 
not confirmed, however, by an autopsy. 1 

It has been generally stated that when this process is broken off, it 
will be carried downwards by the united action of the pectoralis minor, 
the short head of the biceps, and the coraco-brachialis muscles ; but this 
will depend upon whether the coraco-clavicular ligaments are ruptured 
also ; a circumstance which is not very likely to occur, at least to any 
great extent ; and in fact not one of the well-attested examples of this 
fracture has ever been accompanied with any considerable displacement 
in this direction. 

Treatment.-. — In a case of simple fracture of the process, unattended 
with any other lesions, it has been recommended to place the arm in a 
sling, with the elbow advanced as much as possible upon the front of the 
chest, as by this position we relax somewhat all of the three muscles 
having attachments to this process, and then to confine the scapula by a 
few turns of a roller. It is not probable, however, that by these meas- 
ures we would accomplish enough to justify their continuance if they 
were found to be painful, or even exceedingly irksome. Patients under 
my observation have generally complained very much of the pain and 
discomfort attending this position of extreme flexion of the arm and fore- 
arm, first employed by Velpeau for fractures of the clavicle. Moreover, 
I do not think the fragments are generally displaced ; and if they were, 
and the final union were to be accomplished solely by ligament, I think 
the usefulness of the arm would not be at all impaired. Such, at least, 
has been my experience in the two cases above recorded, and in both of 
which no bony union occurred. In Dr. Little's case rotation of the 
humerus outwards seemed to effect a reduction, but upon what principle 
precisely this position acted to effect the reduction I am not prepared to 
say ; perhaps by drawing upon the coraco-brachialis and short head of 

1 Huse, Chicago Med. Journ., Aug. 1879. 



FRACTURES OF THE HUMERUS. 233 

the biceps — nor am I prepared to say that it would accomplish the same 
result in any other case, yet it may deserve a trial. 

In the graver forms of the accident, where other bones about the 
shoulder are broken or dislocated, or the limb has suffered other severe 
injuries, which, as we have seen, constitute the larger proportion of the 
whole number, the treatment must generally have little or no regard to 
this particular injury. 



.-5 



CHAPTEE XXI. 

FRACTURES OF THE HUMERUS. 

It is not sufficient to consider fractures of this bone as occurrin 
through the shaft and its two extremities, as some systematic writers 
have done ; since upon this simple arrangement it is impossible to base 
a natural division of their causes, symptoms, prognosis, and treatment. 

We shall find it necessary to consider — 

1. Fractures of the head and anatomical neck. (Intra-capsular ; 
non-impacted and impacted.) 

2. Fractures through the tubercles. (Extra-capsular ; non-impacted 
and impacted.) 

3. Longitudinal fractures of the head and neck, or splitting off of the 
greater tubercle. 

4. Fractures of the surgical neck. (Including separations at the upper 
epiphysis.) 

5. Fractures through the body of the shaft. (Shaft below the surgi- 
cal neck and above the base of the condyles.) 

6. Fractures at the base of the condyles. (Including separations at 
the lower epiphysis.) 

7. Fractures at the base, complicated with fractures between the con- 
dyles, extending into the joint. 

8. Fractures or separations of the internal epicondyle. 

9. Fractures or separations of the external epicondyle. 

10. Fractures of the internal condyle. 

11. Fractures of the external condyle. 

Of 203 fractures of the humerus examined and recorded by me, 51 
occurred through the upper third, 43 through the middle third, and 103 
through the lower third. An observation which is in contrast with the 
statement made by Amesbury, and which has been repeated by Lizars, 
B. Cooper, Fergusson, Gibson, and others, that this bone is most often 
broken in its middle third, unless they intended to speak of fractures of 
the shaft alone. 

Of the fractures belonging to the upper third, 6 were supposed to be 
epiphyseal separations, one w T as probably a fracture at or near the ana- 
tomical neck, with impaction and splitting of the tubercles, one was a 
fracture of the greater tubercle alone, and 44 were fractures at or near 
16 



234 FRACTURES OF THE HUMERUS. 

the surgical neck ; some of them probably involving the shaft below the 
neck. 

Of the fractures belonging to the lower third, 22 were through the 
internal condyle, "29 through the external condyle, 18 were at the base 
of the condyles, 6 through the condyles and across the base at the same 
time. One at the epiphysis, the remaining 27 being through the shaft, 
but above the base. 

Unfortunately, surgical writers have not been agreed in the use and 
application of the terms "head," "neck," "anatomical neck," and " sur- 
gical neck" of the humerus ; and, as a consequence, their meaning is 
often obscure, and their teachings are sometimes contradictory and 
absurd. 1 It is necessary, therefore, that we should define them more 
precisely. 

The "head" of the humerus is that smooth, elliptical surface, covered 
by cartilage and synovial membrane, which articulates with, and is re- 
ceived into, the glenoid cavity of the scapula. 

The " anatomical" neck is the narrow line immediately encircling the 
head, and which receives the insertion of the capsular ligament. 

The " surgical" neck is that portion which commences at the lower 
margin of the tubercles, or at the point of junction between the epiphy- 
sts and the diaphysis, and which terminates at the insertion of the pec- 
toralis major and latissimus dorsi. 

The "neck" is all of that portion included between the head and the 
insertions of the pectoralis major and latissimus dorsi ; comprising not 
only the anatomical and surgical necks, but also the tubercles ; which 
latter occupy the triangular space between these two. 

§ 1. Fractures of the Head and Anatomical Neck. (Intracapsular; 
Non-impacted and Impacted.) 

Causes. — The causes which have been found competent to produce 
fractures of the head and anatomical neck are, the penetration of balls 
or of other missiles directly into the joint, producing thus a compound, 
and generally comminuted, fracture of the head ; and falls, or direct 
blows upon the shoulder, without penetration. 

.Pathology, Results, etc. — When the fracture results from the direct 
penetration of some foreign body into the joint, it is not only a compound 
fracture, but the head of the bone is almost necessarily broken into frag- 
ments. If the patients recover, sooner or later the fragments have gen- 
erally to be removed. 

Fractures of the anatomical neck, produced by falls upon the shoulder, 
without penetration, are, however, usually neither compound nor commi- 
nuted ; and they sometimes follow, with a remarkable degree of accu- 
racy, the line of the insertion of the capsular ligament, being always, 
according to Robert Smith, within the interior or outer margin of this 
insertion. He calls them, therefore, intracapsular. It is probable, 
however — since, as we shall presently see, bony union is not denied to 

1 Boston Med. and Surg. Journ., June 24, 1858, p. 410. 



FRACTURES OF HEAD AND ANATOMICAL NECK, 235 

this fracture — that the line of separation is not always, or generally, 
perhaps, completely within the insertion of the ligament, but that it is in 
some degree extra-articular, if not extracapsular. If 
it is entirely intra-articular, no doubt union of the Fig. 61. 

fragments can never take place ; and necrosis, with 
suppuration, must ensue, demanding, at a period not 
very remote, an operation for the removal of the frag- 
ments, the same as in compound fractures. 

Gibson, however, thinks that the fragment occasion- 
ally remains, being gradually absorbed and changed V 1/ 
in figure. He says that his museum contains three \ v ;, 
or four well-marked cases of this kind, in all of which J 
the head has lost its spherical form, and is very much 
diminished, and rough and flattened next to the scap- 
ula. 1 Other cabinets are said to contain similar 





specimens. 

The displacements to which the upper fragment, or 
the head of the bone, is subject, are remarkable, and 
some of them do not seem to be satisfactorily ex- I 

plained. Frequently, indeed, its position is not sen- „ 

Frflctuvo oi the tiiiti to mi - 

sibly disturbed, but at other times it is found im- caineck. 

pacted, or driven into the cancellous structure of the 
inferior fragment, in consequence of which one or both of the tubercles 
are frequently broken off. 

Robert Smith relates the following case as having afforded him his first 
opportunity of ascertaining by post-mortem examination the exact nature 
of this form of displacement : — 

" A female, set. 47, was admitted into the Richmond Hospital, under 
the care of the late Dr. McDowell, for an injury to the humerus, the 
result of a fall upon the shoulder. Five years afterwards, the woman 
was again admitted, under the care of Mr. Adams, with an extracapsular 
fracture of the neck of the femur, one month after the occurrence of 
which she died, in consequence of an attack of diarrhoea. 

" The shoulder was of course carefully examined ; the arm was slightly 
shortened, the contour of the shoulder was not as full or round as that of 
its fellow, and the acromion process w T as more prominent than natural. 
Upon opening the capsular ligament, the head of the humerus was found 
to have been driven into the cancellated tissue of the shaft, between the 
tuberosities, so deeply as to be below the level of the summit of the 
greater tubercle ; this process had been split off, and displaced outward ; 
it formed an obtuse angle with the outer surface of the shaft of the 
bone.'" 2 

The description is accompanied with tw r o excellent drawings of the 
specimen, showing the distance to which the superior fragment had pene- 
trated the inferior, and showing also complete union by bone. 

I believe, also, that in the following example there was a fracture at 
or near the anatomical neck, with impaction, and splitting of the tuber- 
cles : — 

1 Gibson, Elements of Surgery, vol. i. p. 279. 

2 South, Fractures in Vicinity of Joints, pp. 191-3. 



236 FRACTURES OF THE HUMERUS. 

January 12, 1858. a young man, aged about sixteen years, fell from 
a height in a gymnasium, severely injuring his left shoulder. I saw 
him, with Dr. Boardman, soon after the accident, and found him complain- 
ing very much of the shoulder, which was somewhat swollen and tender. 
He could not tell us how he fell, nor could we discover any contusions 
by which to determine the point where the blow was received. All 
motions of the shoulder-joint were painful ; and there w T as a remarkable 
fulness in front of the joint, feeling like the head of the bone, yet not 
such as is usually present in a forward luxation. To determine this 
more positively, however, the limb was manipulated as for the reduction 
of a dislocation. Once during the manipulation a feeble but distinct 
crepitus was detected ; yet the position of the bone remain unchanged. 
The head was found to be in the socket, but the precise nature of the 
injury was not made out. 

Fifteen days later, when the swelling had completely subsided, a care- 
ful examination was again made by Dr. Boardman and myself, when we 
arrived at the conclusion that it was a fracture through the bicipital 
groove, and that the lesser tubercle was carried forwards half an inch or 
more from its fellow, while the head and the greater tubercle occupied 
their natural positions opposite the socket. The fragment projecting in 
front presented a sharp point, and could not be confounded with any 
swelling of the soft parts. There was a distinct space between the tuber- 
cles, into which the finger could be laid. No depression existed under 
the acromion process behind, but, on measurement, the head of this 
humerus was found to be half an inch wider in its antero-posterior diam- 
eter than the opposite. 

That this fracture was accompanied with impaction was rendered cer- 
tain by the repeated and careful measurements of the length of the hume- 
rus, w T hich constantly showed a shortening of half an inch. 

Under these circumstances union generally takes place ; but it is 
usually accompanied with the formation of an irregular mass of osteo- 
phytes, which encircle the head like a coronet ; presenting in this respect 
again a remarkable resemblance to extracapsular fractures of the neck 
of the femur. This ensheathing callus, as it may be called, is an out- 
growth from the inferior fragment, and it sometimes incloses the upper 
fragment as the case of a watch incloses the crystal, only in a manner 
much more irregular, thus retaining it steadily in its place, although very 
little direct union has occurred. The cancellous tissue, nevertheless, is 
occasionally found united completely by a new and intermediate bony 
tissue, and at other times by a fibrous tissue, or by both fibrous and 
bony tissue. 

In some cases a perfect false joint has been formed between the op- 
posing surfaces ; while in a few unfortunate examples the head not only 
refuses to unite, but by its presence, as we have already remarked, pro- 
duces inflammation and suppuration, resulting in its final extrusion from 
the joint. 

At other times the upper fragment turns upon its own axis, and is 
found more or less tilted or completely rotated in the socket; so that its car- 
tilaginous or articulating surface rests upon the broken surface of the lower 
fragment, and its own broken surface presents toward the glenoid cavity. 



FRACTURES OF HEAD AND ANATOMICAL NECK. 



237 



Robert Smith has described a specimen of this kind which he removed 
from the body of a woman, aged forty, who many years previous to her 
death fell down a flight of stairs, and struck her shoulder with great 
violence against the edge of one of the steps. Whether she applied to 
a surgeon or not at the time of the accident, Mr. Smith was not able to 
ascertain. After death the shoulder looked somewhat as if there was a 
dislocation of the humerus into the axilla, there being a marked depres- 
sion under the acromion process, but the shaft of the humerus was drawn 
upwards and inwards toward the coracoid process. 

When the capsular ligament was opened, the head of the bone was 
found to have been broken from the 



Fig. 62. 



Fig. 63. 




shaft through the line of the ana- 
tomical neck, and to have completely 
turned upon itself; and the carti- 
laginous surface was actually driven 
one inch into the cancellated struc- 
ture of the shaft, so as to split off 
the lesser tubercle with a portion of 
the greater. Only one-half of the 
upper fragment was thus impacted, 
the other half projecting beyond the 
margin of the lower fragment. Be- 
tween the cartilaginous surface and 
the shaft no union had occurred ; 
but there was complete bony union 
between the upper and lower frag- 
ments, beyond the limits of the car- 
tilage. 

The upper surface of the. superior 
fragment rested in part against the 
inner half of the glenoid cavity and 
upon its inner margin, and in part 
it rested against the neck of the 
scapula in the direction of the cora- 
coid process. 1 

Nelaton saw a similar specimen 
in the possession of M. Dubled, the 
revolution of the upper fragment 
being complete ; but there was no 
lateral displacement, and the union 
had been accomplished in a manner 
similar to that which is seen after intracapsular, impacted fractures, 
without reversion. 2 

I have also been permitted to examine a specimen belono-mo- to the 
late Dr. Charles A. Pope, of St. Louis, Mo., which seems to have been 
broken not only through the line of the anatomical neck, but also through 
the surgical neck. Both fragments are united by bone, the lower frao-- 




Pope's Specimen. 



Side view. 



1 R. Smith, op. cit., pp. 193-6. 

2 Nelaton, Elements de Pathol. Chirur., torn, prem., p. 307. 



238 FRACTURES OF THE HUMERUS. 

raent being carried in the direction of the coracoid process, while the 
upper fragment appears to be reversed, so that its articular surface is 
directed toward the shaft, and its broken surface articulates with the 
glenoid cavity. The history of this specimen is unknown. 

Reverting to the histories of the several cases above referred to, in 
which these extraordinary changes of position have taken place, it would 
seem to admit of a doubt whether they were the direct results of the 
accidents which broke the bones, or whether they ensued indirectly, in 
consequence of a chronic arthritis following the accident, and the con- 
stant but long-continued use of the arm. 

There is another theory which, in my opinion, is capable of explain- 
ing most of the phenomena usually present in these cases, and which, 
if admitted, renders the supposition of a fracture unnecessary. It is, 
that in consequence of an injury, perhaps, but not of a fracture, a chronic 
inflammation, softening and absorption has taken place, and that the 
changed position of the head is clue to pressure alone, being acted upon 
by the muscles which surround the joint, and which act all the more 
vigorously because they partake also of the inflammation which has in- 
vaded the bone. This view of these specimens, which had already more 
than once suggested itself to me, was very strongly confirmed by its 
having occupied the mind also of Dr. Neill, of Philadelphia, and who 
at his own instance stated to me that he believed this was their true 
explanation. We were, at the time, examining Dr. Pope's specimen, 
already alluded to, and, on comparing it with a specimen of dislocation 
and partial absorption of the head of the humerus contained in Dr. 
Neill's museum, the points of resemblance were so numerous and strik- 
ing that we felt compelled to doubt whether Dr. Pope's specimen, to- 
gether with those seen by Smith and Nelaton, did not belong to the same 
class with this of Neill's. 

In a case of fracture of the " cervix humeri within the capsular liga- 
ment," examined by Sir Astley Cooper, there was also a complete for- 
ward luxation of the head; but ligamentous union had occurred between 
the fragments. 1 I think it certain that in this case the fracture was not 
entirely within the capsule. 

§2. Fractures through the Tubercles. (Extrascapular ; Non-impacted and 

Impacted.) 

Under this division we intend to speak of all fractures traversing the 
upper end of the humerus, and involving the tubercles ; or of all those 
which occur between the anatomical neck on the one hand, and the epi- 
physeal junction, or surgical neck, on the other hand, and which may be 
more or less oblique as well as transverse. Fractures of the greater or 
lesser tubercles are of course excepted, since, they are more properly 
longitudinal fractures, and do not completely traverse the diameter of 
the bone. Nor do we intend to include those fractures which occur at 
the epiphyseal junction; since, being below the principal insertion of 
those muscles which are attached to the tubercles, they present very 

1 Sir A. Cooper on Dislocations, etc., p. 372. 



LONGITUDINAL FRACTURES OF HEAD AND NECK. 239 

peculiar and distinctive features, which will demand for them a separate 
classification and consideration. 

Causes, Pathology, and Results. — Fractures through the tubercles, 
like fractures through the anatomical neck, are the results generally of 
direct blows received upon the shoulder. They are not usually accom- 
panied with much lateral displacement at the point of fracture ; a circum- 
stance which finds a partial explanation in the fact that the line of fracture 
is through the insertions of the muscles converging upon the tubercles, 
and not entirely above or below them, so that they continue to act nearly 
equally upon both fragments ; but it is also sometimes due in a measure 
to impaction; the head being forced downwards toward the axilla, and 
upon the shaft, until it is made to ride upon its inner or axillary wall 
like a cap; the compact bony tissue of the shaft penetrating the reticular 
structure of the head. These fractures generally unite by bone ; yet 
more or less impairment of the motions of the limb results from the in- 
flammation which occurs in and about the joint, or from the irregular 
deposits of callus in the vicinity of the fracture. 

§ 3. Longitudinal Fractures of the Head and Neck ; or Splitting off of the 

Greater Tubercle. 

Causes, Pathology, Symptoms, and Results. — Mr. Guthrie seems to 
have been the first to call attention to this peculiar injury of the shoulder. 
In a lecture delivered in November, 1833, he described four cases which 
had come under his observation, and which he regarded as examples of 
separation of the small tuberosity, accompanied with more or less of the 
head, the fracture extending along a portion of the bicipital groove. 1 

Robert Smith, however, believes that it was the greater and not the 
lesser tuberosity which was thus detached in the cases mentioned by 
Mr. Guthrie, since the external signs were so nearly like those which 
were present in a woman seen by himself, and in whom an autopsy en- 
abled him to verify his diagnosis. The following is the case as related 
by Mr. Smith: — 

" In July, 1844, 1 was requested to examine the body of Julia Darby, 
set. 80, who had died of chronic pulmonary disease. Upon entering the 
room, the appearances of the left shoulder-joint at once attracted my 
attention, and struck me as being different from those which attend the 
more common injuries of this articulation. 

"The shoulder had lost, to a certain extent, its natural rounded form; 
the acromion process, although unusually prominent, did not project as 
much as in cases of dislocation of the head of the humerus. The breadth 
of the articulation was greatly increased, and, upon pressing beneath the 
acromion, an osseous tumor could be distinctly felt, occupying the greater 
part of the glenoid cavity ; it formed a prominence which was percepti- 
ble through the soft parts ; it moved along with the shaft of the humerus, 
but was manifestly not the head of the bone. 

"A second and larger tumor, presenting the rounded form of the head 
of the humerus, lay beneath the base of, and internal to, the coracoid 

1 Robert Smith, p. 181, from Loud. Med. and Phys. Journal. 



240 FRACTUEES OF THE HUMERUS. 

process, and between the two the finger could be sunk into a deep sulcus, 
placed immediately below the coracoid process. The elbow could be 
brought into contact with the side, and there was no appreciable altera- 
tion in the length of the arm. 

"Upon removing the soft parts, the head of the bone presented itself, 
lying partly beneath and partly internal to the coracoid process. The 
greater tuberosity, together with a very small portion of the outer part 
of the head of the bone, had been completely separated from the shaft 
of the humerus. This portion of the bone occupied the glenoid cavity, 
the head of the humerus having been drawn inwards so as to project 
upon the inner side of the coracoid process ; it was still, however, con- 
tained within the capsular ligament. 

"The fracture traversed the upper part of the bicipital groove, which, 
in consequence of the displacement which the head of the bone had suf- 
fered, was situated exactly below the summit of the coracoid process. A 
new and shallow socket had been formed upon the costal surface of the 
neck of the scapula, below the root of the coracoid process, and the inner 
edge of the glenoid cavity corresponded to the posterior part of the sul- 
cus, which separated the head of the bone from the detached tuberosity. 
The latter was united to the shaft only by ligament. 

"The capsule had not been injured, but was thickened and enlarged, 
and the bone had been deposited in its tissue. The injury had evidently 
occurred many years before the death of the patient, but the history 
connected with it could not be precisely ascertained." 1 

Mr. Smith relates one other case, in the living subject, which he 
saw in connection with Mr. Adams, at the Richmond Hospital, and he 
adds that " numerous" other living examples have fallen under his 
observation. 

Sir Astley Cooper has also published the particulars of a case of 
fracture of the greater tubercle, which was communicated to him by Mr. 
Herbert Mayo. 2 

The following I believe also to have been an example of this rare 
accident: — 

John Hill, set. 78, fell upon the sidewalk, striking upon his right 
shoulder. The physician to w T hom he was sent thought the humerus 
was dislocated, and directed him to the Buffalo Hospital of the Sisters 
of Charity, but he did not apply for admission until eight days after, 
Oct. 14, 1857, when Dr. Boardman and myself examined the limb care- 
fully. 

Although we placed him under the influence of chloroform, the diag- 
nosis was not satisfactorily made out. We inclined, however, to the 
opinion that it was a fracture of the greater tubercle. The antero- 
posterior diameter of the upper end of the bone was greatly increased ; 
there was occasional distinct crepitus, but the limb was not shortened. 

Subsequently, the examinations were repeated many times, and the 
depression between the fragments becoming more palpable, the diagnosis 
was at length confirmed. 

1 Robert Smith, op. cit., p. 178. 

2 Sir A. Cooper, on Dislocations and Fractures of the Joints. Edited by B. Cooper. 
American edition, p. 384. 



FEACTUKES THROUGH THE SURGICAL NECK. 241 

No treatment was adopted, except confinement in bed, and stimulating 
embrocations. Two months after the accident he still remained an inmate 
of the hospital, his shoulder being quite stiff, and the projection continu- 
ing in front. 

Dr. J. J. Charles, demonstrator of anatomy, Queen's College, Belfast, 
has reported a case with great care, which he believes to have been an 
example of this rare accident, and in which opinion I am disposed to 
concur. The man was 30 years old, and it is supposed that the middle 
of the head of the humerus was struck by the pole of a tram car. Dr. 
Charles examined the patient fourteen months after the receipt of the 
injury ; the breadth of the head of the humerus was greatly increased, 
there was a broad sulcus in the situation of the bicipital groove, and the 
humerus was shortened half an inch. The motions of his arm were very 
much limited, especially in abduction. 1 

Mr. Robert Smith thinks that when the displacement is considerable, 
the fragments generally unite by ligament, rather than by bone. 

§ 4. Fractures through the Surgical Neck. (Including Separations at the 

Upper Epiphysis.) 

I have already defined the "surgical neck" as all of that narrow 
portion commencing at the upper epiphysis and terminating at the 
insertion of the pectoralis major and latissimus dorsi. It seems proper, 
therefore, that we should include under this division both fractures 
and separations occurring at the epiphysis, especially since, owing to 
their anatomical relations, they are subject to the same displacements 
as fractures occurring half an inch or one inch lower down ; the 
capsular muscles, with the exception of the teres minor, having no 
more influence over the lower fragment when a separation occurs at 
the epiphysis, than when a separation occurs at any other point of the 
surgical neck. 

Separation at the Upper Epiphysis. — A brief description of the plan 
of development of the humerus will enable the reader better to under- 
stand the occasional separation of the epiphysis, both at the upper and 
lower ends of the bone. 

The humerus is originally formed from seven cartilaginous centres, 
namely, one for the shaft, one for the head, one for the greater tuberosity, 
one for each epicondyle, and two for the lower, articulating end of the 
bone. At birth the shaft is ossified in nearly its whole length. Between 
the first and fourth years ossification commences in the several centres 
composing the upper end of the bone, and they coalesce by the end of the 
fifth year, so as to form a single epiphysis, which finally unites with the 
shaft at about the twentieth year. At the lower end of the bone, ossi- 
fication commences in the radial portion of the articular surface at the 
end of two years, in the trochlear portion at twelve years, in the internal 
epicondyle at the fifth year, and in the external epicondyle at the thirteenth 
or fourteenth. At the sixteenth or seventeenth year all the centres are 

1 J. J. Charles, British Med. Joum., Sept. 26, 1874. 



212 



FRACTURES OF THE HUMERUS 



Fig. 64. 



joined to each other, and to the shaft, except the inner epicondyle, which 
does not unite by bone until about the eighteenth year. It will be ob- 
served, therefore, that although ossification com- 
mences in the upper epiphysis first, it is the last 
to form bony union with the shaft. 

The following is a brief account of all the cases 
of separation at the upper epiphysis which have 
come under my notice : — 

Case 1.— In 1855, Mike Bovin, set. 13 months, 
fell sideways from his cradle, causing some injury 
to his arm near the shoulder. He was taken to an 
empiric, who called it a sprain, and applied lini- 
ments. Three weeks after the accident he was 
brought tome, and I found the arm hanging beside 
the body, with little or no power on the part of the 
child to move it. There was a slight depression 
below the acromion process, and considerable ten- 
derness about the joint ; but the shoulder was not 
swollen, nor had it been at any time. The line of 
the axis of the bone, as it hung by the side, was 
directed a little in front of the socket. 

On moving the elbow backwards and forwards, 
the upper end of the shaft moved in the opposite 
directions with great freedom, and could be dis- 
tinctly felt under the skin and muscles. This mo- 
tion was accompanied with a slight sound, or sensa- 
tion, a sensation not like the grating of broken 
bone, but much less rough. There was no short- 
ening of the limb. When the elbow was carried a 
little forwards upon the chest, the fragments seemed 
to be restored to complete coaptation ; and of this I judged by the re- 
storation of the line of the axis of the shaft to the centre of the socket, 
and by the complete disappearance of the depression under the point of 
the acromion process. 

I applied suitable dressings to retain the arm in this position ; but five 
months after the injury was received the fragments had not united, and 
the child was still unable to lift the arm, although the forearm and hand 
retained their usual strength and freedom of motion. The same crepitus 
could occasionally be felt in the shoulder, and the same preternatural 
mobility. The shoulder was at this time neither swollen nor tender. 

Case 2. — Samuel Robuck, set. 13, fell through a hatchway, July 9, 
1868, striking on his shoulder. He saw a regular physician within five 
hours after the injury was received, who said that the arm was dislo- 
cated; and on the following day, under the influence of chloroform, he 
tried to reduce it. The doctor thought he had succeeded, and he then 
applied bandages to keep it in place. At the end of two weeks the doctor 
declined, for reasons which are not known, to have any further care of 
the case, and the patient consulted Dr. Voss, at the Dispensary. Dr. 
Voss detected the nature of the case, and sent him to me to confirm his 
diagnosis. I found the upper end of the lower fragment projecting in 



Humerus, Avith epiphyses 
(From Gray.) 



FKACTURES THROUGH THE SURGICAL NECK. 243 

front, and not united. The arm was shortened half an inch. I have 
not seen the patient since, and do not know the result. 

Case 3. — Joseph Snellback, set. 16, fell backwards down a flight of 
steps, striking upon his back and arm near the shoulder, May 10, 1868, 
causing a separation of the upper epiphysis of the left humerus. Dr. 

■ , of this city, now deceased, saw the patient within half an hour, 

and supposing that he had suffered a dislocation of the head of the humerus, 
he attempted to effect reduction with his heel in the axilla, and without 
anesthetics. On the following day I found him in Ward 16 at Belle- 
vue. The house-surgeons were divided in opinion as to its character, 
some at first believing it to be a dislocation ; others, with myself, recog- 
nized it to be an epiphyseal separation. 

All efforts at replacement proving ineffectual, splints were applied by 
my direction, and on the loth of July the patient left the hospital with 
the fragments united, but overlapped at the point of fracture, the upper 
end of the lower fragment being in front of the upper fragment. The 
limb was shortened one inch, but its motions were free, and there was no 
reason to suppose that its utility was in any degree impaired. 

Case 4. — C. EL, set. 19, living in a neighboring town, in the delirium 
caused by fever, fell from a third-story window, May 12, 1868. Two 
very intelligent and experienced physicians, who were called, thought the 
boy had received a fracture of the acromion process, accompanied with 
a dislocation of the head of the humerus, and they attempted to reduce 
it, but without success. 

On the 2d of June following, three weeks after the receipt of the in- 
jury, I saw the patient in consultation with his physicians, and found a 
separation of the upper epiphysis of the humerus. The upper end of 
the lower fragment projected in front of the acromion process, appear- 
ing a little above the level of the process, and covered only by the skin. 
No union had occurred between the two fragments. 

Case 5. — John Davis, set. 18, fell about eight feet, September 2, 1873. 
Of the three surgeons first called, Drs. H. and S. thought the boy had 
received a fracture ; the third believed it to be a dislocation, and having 
placed the patient under the influence of ether, attempts were made to 
reduce it. The deformity not being relieved, I was added to the con- 
sultation. I found the shoulder a good deal swollen. The upper end 
of the lower fragment could be felt distinctly in front of the acromion 
process. At first, the surgeons informed me, the broken end seemed just 
under the skin and almost ready to be thrust through, but the extension 
had made it retire somewhat. The end felt rough and serrated. While 
making extension I was able to detect a slight crepitus or click. Em- 
ploying Dugas's test, I found the elbow would rest upon the front of the 
chest. In short, the diagnosis was complete, and Dr. S., having taken 
charge of the case, applied one long splint, and a sling under the wrist, 
but not under the elbow. The fragments have united with very little 
deformity. 1 

This case was subsequently seen by Dr. Moore at one of my Belle vue 
clinics, by whom my diagnosis was fully confirmed. 

1 The Medical Record, May 1, 1874. 



244 FRACTURES OF THE HUMERUS. 

Case 6. — In Nov. 1876, I found in my service, at Bellevue, Wm. 
Hague, set. 19, who, from a fall on the sidewalk, had broken the humerus 
at its upper epiphysis. He says, Dr. Erskine Mason reduced the frac- 
ture on the third' day, and secured the limb with splints. He subse- 
quently tried to reduce it by Moore's method under ether, but was un- 
successful. The displacement was complete, and the entire upper end 
of the lower fragment could be distinctly felt. 

Robert Smith and Sir Astley Cooper both speak of it as a frequent 
accident in early life, but the recorded cases are very few. The case 
mentioned by Mr. Smith has been given very much at length, and, as a 
characteristic example, deserves to be repeated : — 

u During the early part of last year, a boy, eight years of age, was 
admitted to the Richmond Hospital, under the care of Dr. McDoAvell. 
About a week previous to his admission he had fallen upon the shoulder, 
and at once lost the power of using his arm. 

" It was at first sight evident that there did not exist any luxation of 
the head of the humerus, and it was equally obvious that the case was 
not an example of any of the ordinary fractures to which the neck of the 
bone is liable. There was no diminution of the natural rotundity of the 
shoulder, nor any unusual prominence of the acromion process ; the head 
of the bone could be distinctly felt in the glenoid cavity, and it remained 
motionless when the arm was rotated ; there was very little separation 
of the elbow from the side, but it was directed slightly backwards. 

"About three-quarters of an inch below the coracoid process there ex- 
isted a remarkable and abrupt projection, manifestly formed by the upper 
extremity of the shaft of the humerus, every motion imparted to which 
it followed. Its superior surface, which could be distinctly felt, was 
slightly convex, and its margin had nothing of the sharpness which the 
edge of a recently broken bone presents in ordinary fractures. 

" When this projecting portion of the bone was pushed outwards, so 
as to bring it in contact with the under surface of the head of the 
humerus (previously fixed as far as it was possible to do so), a crepitus 
was reduced by rotating the shaft of the bone. It did not, however, 
resemble the ordinary crepitus of fracture, but it would be extremely 
difficult, by any description, to convey a clear idea of what the difference 
consisted in. 

" From a careful consideration of the symptoms and appearances 
above-mentioned (taking into account also the age of the patient), the 
diagnosis was formed, that the injury consisted in a separation of the 
superior epiphysis of the humerus from the shaft of the bone. Various 
mechanical contrivances were employed in this case, but all proved inef- 
fectual in maintaining the fragments in their proper relative position." 1 

Sir Astley Cooper has also briefly described one example, which oc- 
curred in a child ten years of age. 2 

Prof. E. M. Moore, of Rochester, in a paper read before the American 
Medical Association, in 1874, and published in the Transactions for that 
year, has called attention to what he considers the true condition of the 
separated fragments in most of these cases, and to the proper remedy. 

1 Robert Smith, op. cit., p. 201. 2 Sir A. Cooper, op. cit., p. 382. 



FHACTURES THROUGH THE SURGICAL XECK. 24:5 

He observes that the displacement is not usually complete ; but that the 
upper end of the lower fragment is carried inwards to the distance of 
about one-fourth of its diameter, when it is arrested, by a convexity of 
the lower fragment becoming lodged in a natural concavity in the upper 
fragment. The upper fragment now becomes tilted by the action of the 
muscles, its internal margin ascending in the glenoid cavity, and its outer 
margin descending until it is arrested by the capsule. 

Fig. 65. Fig. 66. 








Upper epiphysis of humerus. (From Moore.) Epiphyseal separation. (From Moore.) 



If, under these circumstances, the arm is carried forwards and upwards 
to the perpendicular line, the upper fragment or epiphysis will remain 
fixed, being held fast by the capsule inserted into the outer and poste- 
rior margin of the head, while the lower fragment or diaphysis, aided by 
the natural action of the muscles, will move outwards and resume its 
original position. 

The correctness of this opinion he has verified by having in this man- 
ner effected the reduction with great ease, in three cases which have come 
under his observation. The patients were respectively six, fourteen, and 
sixteen years of age. 

In the first case the reduction was effected on the fourteenth day ; in 
the second case, on the second day ; and in the third, on the seventeenth 
day. In both of the latter, ineffectual attempts had been already made 
to reduce what was supposed to be a dislocation. 

In order to maintain the reduction, it was only found necessary to 
bring the arm down while in a state of moderate extension, and to secure 
it beside the body with a Swinburne extension splint. Any of the forms 
of dressing applicable to a fracture of the surgical neck would probably 
prove equally efficient. 

The observations made by Professor Moore seem to me exceedingly 
valuable ; yet I do not think it always happens that the separation is 
incomplete, nor does Professor Moore say that it is, but that was the 



246 



FEACTUKES OF THE HUMERUS. 



Fig. 67. 



condition in all the cases seen by him. Prof. Pooley, of Columbus, 
Ohio, reports a case occurring in a boy twelve years old, which he was 
unable to reduce by Moore's method. 1 Dr. Richmond reports another 
example in a young man nineteen years old successfully reduced by this 
method. 2 

In Cases 4, 5, and 6, reported by myself, the upper end of the lower 
fragment was above the level of the coracoid process, and seemed to be 
directly beneath the skin. These were probably examples of complete 
separation ; but the remaining three presented the symptoms described 
as characteristic of the partial separation in Professor Moore's paper ; 

the projection was less marked, and on a 
level with the coracoid process, or a little 
below it. 

In all my cases, except the first, the upper 
end of the lower fragment could be felt, not 
sharp or pointed, as in most examples of 
fracture of the surgical neck, but somewhat 
irregularly transverse, and when covered 
with the skin and muscle, might be easily 
mistaken, by the inexperienced, for the head 
of the bone. 

True Fracture at the Surgical Neck. — It 
seems necessary, in order to a full under- 
standing of the varying aspects under which 
this accident occurs, and in order to the 
establishment of the diagnosis, prognosis, 
and treatment, to relate a few illustrative 
examples. 

Case 1. Simple fracture , never displaced; 
union ivithout deformity. — Alex. Balentine, 
aet. 62 ; admitted to the Buffalo Hospital of the Sisters of Charity, De- 
cember 19, 1851. He had fallen upon the sidewalk, striking upon his 
right arm. Dr. Johnson, of Buffalo, had reduced the fracture, and 
applied appropriate dressings. No union of the fragments had yet oc- 
curred ; but as the surfaces were in apposition, it was only after consid- 
erable manipulation, and not until we bent the forearm upon the arm, 
and rotated the humerus by means of the forearm, that the crepitus 
became distinct, and gave unequivocal evidence of the existence of a 
fracture, and of its situation. 

The treatment, after admission, consisted in the application of one 
gutta percha splint, accurately moulded, and extending from above the 
shoulder to below the elbow, and encircling one-half the circumference 
of the arm ; the splint being secured with the usual bandages, etc. 
The result is a perfect limb. 

Case 2. Simple fracture; union, with displacement and deformity . — 
White, of Buffalo, aet. 12, fell fourteen feet, striking on the front and 
outside of the left shoulder. Dr. P., of Erie County, saw the lad within 




Fracture of the surgical neck of th 
humerus. (From Gray.) 



1 Pooley, New York Journ. Med., February, 1875, p. 139. 

2 Richmond, New York Med. Journ., Nov. 1877. 



FRACTURES THROUGH THE SURGICAL NECK. 247 

three hours (July 19, 1853). He was brought to me on the fourth day 
after the accident. The upper part of the arm was then very much 
swollen. I found the arm dressed as for a fracture of the middle or 
lower third of the humerus. It was shortened one inch. The elbow 
was inclined backwards, and there was a remarkable projection in front 
of the joint, feeling like the head of the bone. The hand and arm 
were powerless. I suspected a dislocation of the head of the humerus 
forwards ; and, having administered chloroform, I attempted its reduc- 
tion with my heel in the axilla. While making extension, I felt a 
sudden sensation like the slipping of the bone into its socket, but on 
examination I found the projection continued as before. I then repeated 
the eifort, with precisely the same result. 

I now applied an arm-sling, and directed leeches and cold evaporating 
lotions. 

On the 25th, five days after the accident, it was examined by Drs. 
Mixer, McGregor, Joseph Smith, with myself. We still believed it was 
a dislocation, and, having administered chloroform, we again attempted 
its reduction. The same slipping sensation was produced as before, and 
the deformity was repeatedly made to disappear ; but, on suspending 
the extension, it as often reappeared. 

The character of the. accident was now made apparent, and we pro- 
ceeded at once to apply the splint and bandages suitable for a fracture 
of the surgical neck of the humerus, namely, a gutta-percha splint, ex- 
tending, on the outside, from the top of the shoulder to below the elbow, 
with an arm and body roller secured with flour paste. 

On the 31st, twelve days after the accident, Dr. Wilcox, Marine Sur- 
geon at Buffalo, saw the arm with me. The fragments were displaced 
the same as when I first saiv it, and the same as when no apparatus was 
applied. We examined it again carefully, and attempted to make the 
fragments remain in place, but we were unable to do so, except while 
holding them and making extension. 

August 9 (twenty-first day). I removed all the dressings. Motion 
between the fragments had ceased, but the projection and shortening 
remained as before ; now, also, the irregular projections of the fractured 
bones w T ere more distinctly felt. The dressings were never reapplied. 
Three months later no change had occurred. He could carry the elbow T 
forwards freely, as well as backwards, the motions of the shoulder-joint 
being unimpaired. 

Case 3. Simple fracture, with displacement ; resulting in deformity 
and non-union. — L. B., of Lockport, set. 43, was thrown from his horse 
in February, 1854, striking upon his right elbow r . 

Dr. Maxwell, an experienced surgeon of Lockport, examined and 
dressed the fracture. Dr. Fassett was present and assisted at a subse- 
quent dressing. Three surgeons, who examined the arm before Dr. M., 
called it a dislocation. 

Twelve weeks after the accident, Mr. B. called upon me. The right 
arm was shortened one inch ; the elbow hung off slightly from the body; 
the upper end of the lower fragment was distinctly felt in front of the 
shoulder-joint, under the clavicle, feeling very much like the head of 
the bone. The fragments were not united, but they could be seized 



248 FEACTURES OF THE HUMERUS. 

easily, and made to move separately and freely. He stated to me that 
he was subject to rheumatism, and especially in the shoulder and arm 
of the side injured. He wished to know whether it could not be " reset." 

Two years after, I found the bone still ununited. He was, however, 
able to write with that hand, having first lifted his arm with the other 
hand and laid it upon the table. 

Case 4. Simple fracture, probably impacted; resulting in deform- 
ity. — Wm. A., of Buffalo, set. 15, fell backwards, June 4, 1855, striking 
on his back and left shoulder. Dr. L. saw it immediately, and, regard- 
ing it as a dislocation, attempted its reduction. He subsequently re- 
peated the attempt. I saw the patient with Dr. L. on the tenth day. 
The arm was shortened one inch and a half. The fragments were dis- 
placed forwards, projecting in front of and a little below the joint. As 
in Case 3, it might easily be mistaken for the head of the bone ; but the 
difficulty of diagnosis had been very much lessened by the subsidence 
of the swelling. There was no motion between the fragments ; nor 
coulcl the deformity, by any manipulation or extension, be made to dis- 
appear. It was probably impacted. 

March 23, 1856, nearly ten months after the accident, I found the 
fragments remaining as when I first examined the limb, and the arm 
shortened one inch and a half. The elbow hung a very little back from 
the line of the body. The upper end of the lower fragment w r as lifted 
to within one inch of the head of the humerus ; the upper fragment 
having its head in the socket, with its lower end downwards and for- 
wards. The arm was, however, in every respect as useful as before it 
was broken. It was equally strong, and he could raise his arm as high 
and move it in every direction as freely as he could the other. 

Causes. — Epiphyseal separations belong almost exclusively to the 
periods of youth and childhood, but true fractures at the surgical neck 
occur most often in adult life ; with the exception of one girl and two 
lads, aged, respectively, eleven, twelve, and fifteen years, all of the 
examples of this latter accident recorded by me (44) occurred in adults ; 
yet Sir A. Cooper declares these fractures to be most common in in- 
fancy, while Malgaigne has never seen a case in a person under fifty- 
three years. 

Both epiphyseal separations and fractures at this point are occasioned, 
in most cases, by direct blows or falls upon the shoulder. Of thirty- 
one examples in which I find the cause recorded, twenty-two were from 
direct blows, eight from indirect blows, and one from muscular action, 
as in throwing a ball. Of the eight resulting from indirect blows, one 
was from a fall upon the hand, seen by Desault, and seven were from 
falls upon the elbow, of which two were seen by Desault, and five by 
myself. 

Pathology. — I have found the fragments sensibly displaced in twelve 
cases out of seventeen ; a proportion much greater than has been ob- 
served by Malgaigne, who has only seen a displacement twice in more 
than twenty cases. It is certain, however, that complete or sensible 
displacement is less common in this fracture than in most other fractures, 
the broken ends being retained in place, probably, by the long tendon of 
the biceps, and the long head of the triceps. 



FEACTURES THROUGH THE SURGICAL NECK. 249 

As to the direction of the displacement, I have generally found the 
upper end of the lower fragment drawn forwards and upwards toward 
the coracoid process ; in one of which examples the upper fragment 
plainly followed in the same direction. Sir Astley Cooper declares that 
with infants this direction is constant, and in museum specimens I have 
seen but one exception. In the specimens of fracture of the surgical 
neck, with also displacement of the head, belonging to Dr. Pope, this 
direction of the fragments is plainly seen, as also in one of the specimens 
belonging to Dr. Neill, of the Pennsylvania Medical College, where the 
lower fragment almost reaches the coracoid process, and in a specimen 
contained in one of the cabinets of the University of Pennsylvania, where 
the upper end of the lower fragment has become united by bone to the 
coracoid process. 

The only exception which I have met with is in the possession of Dr. 
Neill. In this example the two ends are tilted toward the axilla. I am 
compelled, therefore, to doubt the accuracy of Malgaigne's observations, 
who thinks he has seen the lower fragment most often drawn toward the 
axilla, as well as the observations of those who think that the upper frag- 
ment is generally displaced outwards ; yet, no doubt, they do sometimes 
assume this position. Desault has seen them both thrown backwards ; 
while Dupuytren, Paletta, and others have seen them pushed outwards ; 
and I have in my collection the copy of a specimen in which both frag- 
ments are drawn ontwarcls, but the lower fragment is to the inner side 
of the upper. 

When the fracture occurs at or near the epiphysis, it is sometimes ac- 
companied with impaction, of the same character as we have already 
described when speaking of fractures through the tubercles. Robert 
Smith has given, in his treatise, an engraving intended to illustrate the 
relative position of the fragments in extracapsular impacted fractures, 
and the line of separation very nearly corresponds to the line of junction 
of the epiphysis with the shaft. 

But in a majority of cases no impaction occurs. Dr. Charles A. Pope, 
of St. Louis, Mo., has two specimens of this kind, in which no union has 
taken place, nor is there any evidence that impaction had ever occurred. 
In one case the line of fracture commences at the junction of the head 
with the shaft, and extends thence irregularly across to a point half an 
inch below the greater tuberosity. In the second specimen the fracture 
commences at the same point, and terminates three-quarters of an inch 
below the greater tuberosity. In relation to these bones, Dr. Pope 
remarks : " These are not cases of detachment of the epiphyses, as the 
bones are evidently those of adults, and there is, at their lower extremi- 
ties above the condyles, no trace of an epiphyseal line." 

Results. — Sixteen of the examples of fracture of the surgical neck 
recorded by me are known to have resulted in perfect limbs ; that is to 
say, there is no displacement, overlapping, or shortening, and the pa- 
tients have recovered the free use of the limbs. These were all, prob- 
ably, examples in which no displacement ever occurred. Of the remain- 
der, all, so far as I have been able to determine, have united with some 
displacement ; but in nearly all the functions of the limb have been fully 
or almost fully restored. The only exception I can recall is the single 
17 



250 FRACTURES OF THE HUMERUS. 

one in which no bony union ever took place (Case 3, Report on Def. 
after Frac). 

Symptoms, or Differential Diagnosis of Accidents about the Shoulder- 
joint. — No place could be more appropriate than this to call attention 
to the difficulty of diagnosis in the case of accidents about the shoulder- 
joint, a difficulty which surgeons have constantly recognized, and which 
has sometimes rendered diagnosis impossible. 

Let us first study the ordinary signs of a dislocation at the shoulder- 
joint, regarding this as the type with which the other accidents are to 
be compared. 

a. Signs of a Dislocation. (Cause, generally a fall upon the elbow 
or hand, yet not very unfrequently a direct blow.) 

1. Preternatural immobility. 

2. Absence of crepitus. 

3. When the bone is brought to its place, it will usually remain with- 
out the employment of force. 

These three are common signs, which apply to any other joint as well 
as to the shoulder. 

4. Inability to place the hand upon the opposite shoulder, or to have 
it placed there by an assistant, while at the same time the elbow touches 
the breast. This is a sign common to all of the dislocations of the 
shoulder. 1 

The following are special signs, or such as belong only to particular 
dislocations of the shoulder. 

5. Depression under the acromion process ; always greatest under- 
neath the outer extremity, but more or less in front or behind, according 
as the dislocation may be into the axilla, forwards or backwards. 

6. Round, smooth head of the bone sometimes felt in its new situa- 
tion, and very plainly removed from its socket ; moving with the shaft. 
Absence of the head of the bone from the socket. 

7. Elbow carried outwards, and in certain cases forwards or back- 
wards, and not easily pressed to the side of the body. 

8. Arm lengthened in the subcoracoid and subglenoid dislocations ; 
and only shortened in the subclavicular and subspinous. Occasionally, 
in old cases, the head of the humerus, leaving the subglenoid position, 
becomes subscapular, being placed upon the centre of the scapula, and 
thus, also, the arm is shortened. 

b. Signs of a Fracture of the Neck of the Scapula. (Cause, gen- 
erally a direct blow ; exceedingly rare.) 

1. Preternatural mobility. 

2. Crepitus, generally detected by placing the finger on the coracoid 
process, and the opposite hand upon the back of the scapula, while the 
head of the humerus is pushed outwards and rotated. 

3. When reduced, it will not remain in place. 

4. The hand may generally, but with difficulty, be placed upon the 
opposite shoulder, with the elbow resting upon the front of the chest. 

1 Report on a New Principle of Diagnosis in Dislocations of the Shoulder-joint, by 
L. A. Dugas, Prof, of Surgery in the Medical College of Georgia. Trans. Amer. Med. 
Assoc, vol-, x. p. 175. 



DIFFERENTIAL DIAGNOSIS OF ACCIDENTS. 251 

5. Depression under the acromion process, but not so marked as in 
dislocation. 

6. Head of the bone may be felt in the axilla, but less distinctly than 
in dislocation. Never much forwards or backwards. Head of the bone 
moves with the shaft. Head of the bone not to be felt under the acro- 
mion process, although it has not left its socket. 

7. Elbow carried a little outwards, but not so much as in dislocation. 
Easily brought against the side of the body. 

8. Arm lengthened. 

9. The coracoid process carried a little toward the sternum, and 
downwards. 

10. Pressing upon the coracoid process, it is found to be movable, 
and it is also observed that it obeys the motions of the arm. 

c. Signs of a Fracture of the Lower or Anterior Lip of the Glenoid 
Cavity. Not yet fully determined. 

d. Signs of Fracture of the Anatomical Neck of the Humerus. 
Intracapsular. (Cause, a direct blow; generally opening to the joint, 
but not always.) 

1. Mobility not increased, nor diminished. 

2. Crepitus, generally discovered by pressing up the head of the 
bone into its socket and rotating ; or, when the tubercles are also 
broken, by grasping the tubercles and rotating the arm. 

3. Fragments not generally displaced. 

4. The hand can be placed easily upon the opposite shoulder, with the 
elbow against the front of the chest. 

5. Very slight, if any, depression under the acromion process. 

6. Head of the bone generally in its socket, but not felt so distinctly 
as before the fracture. 

7. Elbow falls easily against the side of the body, or is easily placed 
there. 

8. Arm not lengthened, nor appreciably shortened, unless the head 
be driven so much into the body as to separate the tubercles. 

9. In this latter case there are present also the signs of fracture of 
the tubercles. 

e. Signs of Fracture of the Humerus through the Tubercles. Extra- 
capsular. {Cause, direct blows.) 

1. Generally, there is neither marked mobility nor immobility, ex- 
cept what immobility may be clue to a contusion of the muscles. 

2. Crepitus, discovered, but not so easily as in intracapsular frac- 
tures, by rotating the arm while the tubercles are grasped firmly. 

3. If displacement exists, the fragments are not always easily kept 
in place when once reduced. 

4. The hand can be placed upon the opposite shoulder, with the 
elbow against the front of the chest. 

5. No depression under the acromion process. 

6. Head of the bone in its socket, and moving with the shaft, when, 
as is usually the case, it is impacted. 

7. Elbow hangs against the side of the body. 

8. Arm shortened when impacted, but not much. 

The signs which characterize this accident are more obscure than in 



252 FRACTURES OF THE HUMERUS. 

either of the other shoulder accidents. They are mostly negative, and 
will not generally be determined positively except in the autopsy. 

f. /Signs of a Longitudinal Fracture of the Head and Neck, or 
splitting off of the Greater Tubercle. (Cause, direct blow upon the 
front of the shoulder.) 

1. Mobility of the limb natural. 

2. Crepitus; elicited especially by grasping the tubercles and rotat- 
ing the arm, or by carrying it up and back and then rotating. 

3. When reduced, the fragments will not remain in place. 

4. The hand can be placed upon the opposite shoulder, while the 
elbow rests against the front of the chest. 

5. Some depression under the acromion process. 

6. A smooth bony projection directly underneath the coracoid process, 
or close upon its inner or outer side, moving with the shaft. The head 
of the bone cannot be felt in the socket, yet the space under the acro- 
mion is not entirely unoccupied. 

7. Generally, but not always, the elbow hangs against the side. 
Sometimes it inclines a little backwards. It can always be easily 
brought to the side. 

8. Arm generally neither lengthened nor shortened. 

9. A remarkable increase in the antero-posterior diameter of the 
upper end of the bone. 

10. A deep vertical sulcus between the tubercles, corresponding with 
the upper part of the bicipital groove. 

g. Signs of a Fracture through the Surgical Neck. {Cause, gener- 
ally direct blows, but in old people frequently caused by a fall upon the 
elbow.) 

1. Preternatural mobility often, but not constantly, present. 

2. Crepitus, produced easily when there is no impaction, or when the 
displacement is not complete, but with difficulty when impaction exists 
or the displacement is complete. 

3. When once the fragments have been displaced, it is exceedingly 
difficult ever afterward to maintain them in place. 

4. The hand can be easily placed upon the opposite shoulder, while 
the elbow rests against the front of the chest. 

5. A slight depression below the acromion, not immediately under- 
neath its extremity, but an inch or more below. 

6. Head of the bone in the socket, and moving with the shaft when 
impacted, but not moving with the shaft when not impacted. The 
upper end of the lower fragment being often felt distinctly pressing 
upwards toward the coracoid process ; its broken extremity being easily 
distinguished by its irregularity from the head of the bone. 

7. Elbow hanging against the side when the fragments are not dis- 
placed, but away from the side when displacement exists. 

8. Length of arm unchanged unless the fragments are impacted or 
overlapped ; or both fragments are much tilted inw r ards. If the frag- 
ments are completely displaced, the arm is shortened. 

h. Signs of a Separation at the Epiphysis. (Cause, direct blows.) 
1. Preternatural mobility. 



DIFFERENTIAL DIAGNOSIS OF ACCIDENTS. 253 

2. Feeble crepitus ; less rough than the crepitus produced when 
broken bones are rubbed against each other. 

3. Fragments replaced are not easily maintained in place, unless the 
reduction has been effected by Moore's method. 

4. Same as in preceding variety of fracture. 

5. The depression is not immediately under the acromion, yet higher 
than in most fractures of the surgical neck, perhaps one inch below the 
acromion process. 

6. Head of the bone in its socket, and not moving with the shaft. 
Upper end of lower fragment projecting in front, when displacement 
exists, and feeling less sharp and angular than in case of a broken 
bone ; indeed, being slightly convex and rather smooth, it may easily be 
mistaken for the head of the bone. 

7. Same as preceding variety. 

8. Length of arm not changed unless the fragments are overlapped, 
or both fragments are tilted upon each other. When the fragments are 
overlapped, the arm is shortened. 

9. This accident is peculiar to the young. It can seldom occur after 
the twentieth year. 

There are other accidents about the shoulder-joint, such as a patho- 
logical partial luxation of the humerus, dislocation of the tendon of the 
biceps, etc., which might possibly be confounded with fractures, but the 
consideration of which I shall reserve for another time. 

My readers will here permit me to quote at length a portion of a clin- 
ical lecture delivered by myself at Bellevue Hospital, in 1875, calling 
attention to two new differential signs 1 : — 

" Examples of errors of diagnosis in the case of injuries involving the 
shoulder-joint are very frequent. My personal experience furnishes me 
with probably forty or fifty cases in which the head of the humerus has 
been supposed to be dislocated when it was not ; or in which it has been 
supposed to be broken when it was not. For this reason it is important 
that we be informed of every known means of diagnosis ; and to those 
which are already known and published I will now add two more, of 
which we will be able pretty often to avail ourselves. 

" When the head of the humerus is in its socket it projects outwards, 
beyond the extremity of the acromion process, from half an inch to an 
inch ; varying more or less according to the age and size of the person. 
It projects also in front of the acromion process a little, but not at all 
behind'. 

" In case of a dislocation, in whatever direction the head of the 
humerus is displaced, there can be no bony projection outwards beyond 
the acromion process. This fact may be ascertained always, unless 
there is very great swelling of the soft parts over the point of the shoul- 
der ; but it will be necessary that we should be familiar with the natural 
outline of the acromion process, and this is a study which medical men 
too much neglect, namely, the study of the natural form of the surface 
of the body, or what I call ' Superficial Anatomy.' We must learn to 

1 Two New Differential Signs of Dislocation of the Shoulder. Clinical Lecture by 
the author at Bellevue Hospital. Med. Record, March 27, 1875, p. 220. 



254 FRACTURES OF THE HUMERUS. 

know where is the outer end of the clavicle, where is the outer end of 
the acromion process, and where is the c.oracoid process, if we expect to 
determine the existence or absence of a dislocation of the shoulder. 
This exercise you can pursue in your bedrooms, on your own persons 
or on the persons of others. With a camel's-hair pencil, moistened with 
the tincture of iodine, you can mark out upon the skin the line of the 
clavicle, acromion process, spine of the scapula, etc. In attempting this 
for the first time you will probably find that there is much to learn that 
you did not know before, however thoroughly you have studied the 
anatomy of the shoulder in the dissecting-room, when the skin is re- 
moved. The same applies to all the other joints of the body ; and now 
you will understand why some men, perhaps wholly ignorant of anatomy 
as it is usually taught, but familiar by long practice with superficial 
anatomy, will recognize in a moment the nature of a joint injury, which 
you may fail after a very careful examination to detect. 

" Let us return to the consideration of the two special signs of shoulder- 
joint dislocation (liable to only one exception, as I shall hereafter 
explain), which I wish to add to those already given by surgical writers. 

" First. While the head of the humerus remains in its socket, if a rule 
be laid upon the outside of the arm from the shoulder to the elbow, it 
will not touch the acromion process, but will be distant from it at least 
half an inch, generally one inch or more. On the other hand, if the 
bone is removed from the socket, in whatever direction it may be dis- 
placed, whether forwards, downwards, or backwards, unless the shoulder 
is much swollen, the rule, placed in the manner above stated, will touch 
the acromion process. 

" Second. If, standing behind the patient (in case of the right shoul- 
der), the thumb and forefinger of the left hand is made to grasp the top 
of the shoulder in such a manner that the interdigital commissure shall 
rest upon the acromion process, just outside of the acromio-clavicular 
articulation ; and if then the finger and thumb are dropped perpendicu- 
larly, the tip of the finger will (in case the head of the humerus is not 
dislocated) rest upon the centre of the round upper extremity of the 
humerus, as it projects in front of the acromion process, while the end. of 
the thumb will rest upon the head of the humerus behind ; but the head 
will be felt indistinctly by the thumb, for the reason that, instead of pro- 
jecting as it does in front, it actually recedes a little beneath the acro- 
mion process. Up to this moment the surgeon may entertain some 
doubt whether he is actually grasping with his thumb and finger the 
head of the bone ; but if he now moves the elbow of the injured limb 
forwards, so as to carry the head of the humerus backwards in its 
socket, he will feel it press strongly upon the thumb, and this will be 
conclusive. If a dislocation exists, the head of the bone cannot be felt 
in this situation, and by the thumb thus placed. 

"As we have said before, both of these differential signs, in their 
application to shoulder-joint injuries, are liable to one exception. The 
phenomena would be the same, so far as these two signs are concerned, 
whether there was a dislocation of the head of the humerus, or a frac- 
ture with displacement of the neck of the scapula. The latter accident 
must, therefore, be first excluded by a careful application of the rules of 



FRACTURES OF THE ANATOMICAL NECK. 255 

diagnosis given in our treatises upon surgery ; but that upon which you 
can most safely rely is the relative infrequency of the two accidents. 
It is doubtful whether a long and active surgical practice will ever fur- 
nish you with an example of fracture of the neck of the scapula, while 
}^ou will meet with a great many cases of dislocation of the shoulder." 

Treatment. — I have already spoken of the treatment of fractures of 
the neck of the scapula, and my remarks will now be confined to frac- 
tures of the upper end of the humerus. 

Fractures of the Anatomical Neck ; Intracapsular. — As has already 
been stated, these are generally compound fractures, and, from the ex- 
tent of the injury, often demand resection, or amputation of the entire 
arm. If an effort is made to save the arm, splints will not be applied, 
and the treatment will have little or no reference to the existence of a 
fracture ; it will be directed only to the reduction or prevention of the 
inflammation, etc. 

Simple fracture of the anatomical neck, if not entirely within the 
capsule, without any external wound communicating with the joint, and 
accompanied, as it is sometimes, with impaction, may unite, or the upper 
fragment may become incased in the lower. 

It is not proper in such cases to employ great violence for the purpose 
of detecting crepitus, lest the fragments should become displaced ; and 
if the arm should be found to be a little shortened, it must not be ex- 
tended, with a view to overcoming the shortening, since upon the impac- 
tion probably depend, in a great measure, the chances of union. 

The elbow and forearm may be suspended in a sling, while the arm 
is gently supported against the side, merely to insure quietude. No 
splints are necessary or useful. 

Treatment of Fractures through the Tubercles {Extracapsular) ; Non- 
impacted and Impacted. — In these cases, also, the fragments being 
seldom displaced, very little if any mechanical treatment is demanded. 
A sling is all that is usually required. If, however, on account of dis- 
placement of the fragment, a splint is thought necessary, it must be 
applied in the manner hereafter to be directed in cases of fractures of 
the surgical neck. 

If impaction, with shortening, exists, the same remarks are applicable 
here as in intracapsular impacted fractures, namely, that we ought not 
to rotate the limb much, nor violently, in order to discover crepitus, nor 
make extension with the view of overcoming the shortening, since the 
fragments unite more promptly and certainly when the impaction re- 
mains, and its continuance in no way damages the usefulness of the 
limb. 

Treatment of Longitudinal Fracture of the Head and Neck, or of a 
Separation of the Greater Tubercle. — In the only instance which I have 
recognized as a fracture of the greater tubercle, and already referred to, 
the displacement was moderate, and could not be overcome either by 
change of position or by pressure with extension. The patient was 
therefore merely laid upon his back in bed. No dressings of any kind 
were employed, and the fragments seemed to unite promptly, and with 
no increase in the displacement. 

If the displacement is originally more considerable, attempts ought 



256 FRACTURES OF THE HUMERUS. 

still to be made to reduce the fragments, by extension and abduction 
of the arm, with direct pressure ; yet they will not generally prove 
completely successful, nor will it be found easy to retain them when 
reduced. 

Mr. Mayo treated a fracture of this character, which occurred in a 
man of sixty years of age, with a figure-of-8 bandage, and a sling, with 
a lathe splint on the other side of the humerus, the upper part of which 
was made to bear on the fragments, by uniting the upper part of the 
circular arm roller to the figure-of-8 bandage. " The fracture united 
favorably," he says, but we presume that he does not mean to affirm 
that it united without any degree of displacement ; a result which prob- 
ably ought never to be expected. Mr. Mayo adds, however, that " for 
a long time the patient had some difficulty in carrying the arm back- 
wards." 1 

Treatment of Fractures of the Surgical Neck, including Separations 
at the Epiphysis. — We have already considered the value of Moore's 
method of reduction in cases of incomplete epiphyseal separations of 
the upper end of the humerus ; but the reduction having been accom- 
plished, I see no reason to suppose that the indications of treatment can 
essentially vary in separations at the epiphysis from those in true frac- 
tures through any part of the surgical neck, since the relative action of 
the muscles remains the same, and the direction of the displacement is 
generally the same. My remarks, therefore, upon this point may be 
considered as equally applicable to fractures and epiphysary separations. 

In a considerable proportion of these cases not much displacement of 
either fragment takes place, and consequently we have only to apply 
such moderate retentive means as will insure quiet. Indeed, under such 
circumstances we might not hesitate to adopt the posture treatment 
practised by Dupuytren in two cases, both of which terminated favor- 
ably. The treatment consisted in placing the arm, semi-flexed, on a 
pillow, the pillow being arranged so as to form a pyramid, the summit 
of which was lodged in the axilla, while the elbow was secured to the 
side of the body by a bandage. 2 

Unhappily, however, as we have seen, this condition is not always 
present ; the most frequent form of displacement being that in which the 
lower fragment is drawn upwards and inwards, or toward the coracoid 
process. 

In such cases it will require, often, no little perseverance and skill to 
effect reduction, if it is not found to be actually impossible, and still 
more to retain the bones in place when once reduced. Indeed, it is 
proper to say that a complete reduction is seldom accomplished and per- 
manently maintained, owing, probably, to the advantageous action of 
the muscles which tend to produce the displacement, and in part also to 
the difficulty of applying any apparatus or dressing which shall act effi- 
ciently upon the fragments. 

Sir Astley Cooper recommends for this accident a couple of splints, 

1 B. Cooper's edition of Sir A. Cooper on Dislocations, etc., American edition, 
p. 835. 

2 Dupuytren on Bones, Sydenham edition, p. 99. 



TREATMENT OF FRACTURES OF SURGICAL NECK. 



:.) i 



Fig. 70. 



to be placed one in front of and one behind the shoulder, an axillary 
pad, a clavicular bandage, and a sling ; the sling being made to suspend 
only the wrist and not the elbow, since he had observed that when the 
elbow was lifted the upper end of the shaft was inclined to fall forwards. 

Mr. Tyrrel informed Mr. Cooper that in a similar case he had found 
the bone best maintained in its natural position by its being raised and 
supported at right angles with the side, by a rectangular splint, a part 
of which rested against the side, while the arm reposed upon the other 
part ; and until he had made use of this plan, he could not succeed in 
removing the deformity, or in keeping the bone in its place. 

The following is the plan which I have myself generally pre- 
ferred: — 

Two splints are prepared, made of felt, gutta percha, gum shellac 
cloth, or leather. The two latter are the most economical, generally 
most easily obtained, and 

answer the purpose as Fig. 68. Fig. 69. 

well as either of the 
others. The leather to 
be employed should be 
sole leather, of medium 
thickness, and hemlock 
tanned. (See General 
Treatment of Fractures, 
Chapter VI.) 

The " long" splint must 
be lonor enough to extend 
from the top of the acro- 
mion process to a point 
just above the external 
condyle. The form of 
the splint, before it is 
moulded, is represented in 
the accompanying wood- 
cut, Fig. 68. It is then 

to be bevelled or thinned along its edges by shaving a thin ribbon from 
the margins on the side which is to be laid against the arm ; a few holes 
are to be made with a brad-awl on the margins of the V-shapecl section 
at the upper end. If leather is used, having soaked the splint in water, 
until it is rendered slightly flexible, it is rolled up from its two sides 
until it has the natural curve of the circumference of the arm. If it is 
wet too much it will yield under the pressure of the bandages, and this 
is not desirable. It ought to be straight, or nearly so, in its longi- 
tudinal axis, except at the top, where it embraces the end of the 
shoulder ; and it should be inflexible when applied, the splint touching 
the arm firmly only over the head and tuberosities, and along the lower 
portion of the humerus. The V-shaped section at the top of the splint 
is then closed with strong linen, or shoemaker's thread ; and in order 
to give it a more regular curve, and to render it smooth, it may be 
hammered. 

Some of the splints which surgeons prepare, in imitation of this gen- 



Sliort splint. 



Plan of author's lon< 
leather arm splint. 



Long leather splint 
closed at top, and in 
shape. 



258 FRACTURES OF THE HUMERUS. 

eral plan, extend too far upon the shoulder, and are liable to be dis- 
turbed in the motions of the neck or of the arm. It is only necessary 
that the splint should embrace the shoulder sufficiently to prevent its 
sliding down. The splint will now be completed by inclosing it in a 
loose flannel sack, stitched on the outside. If the arm is swollen and 
tender, or the skin very delicate, a thin sheet of cotton wadding should 
be laid between the cover and splint. 

The " short" splint made of leather, or gum shellac cloth — binders' 
board will answer equally well — carefully trimmed, and covered with 
flannel cloth, must have sufficient length to extend from the free margin 
of the axilla to the internal condyle, taking care that it shall not touch 
either. The purpose of this splint is not to support the fragments, for it 
is apparent that it cannot extend so high, even, as the point of fracture ; 
but it is solely to protect the delicate skin beneath the arm from the 
bandages, which are apt to form cords and cause excoriations. In this 
point of view it is of great importance, and cannot properly be omitted. 

The splints being laid upon the arm, and while extension and counter- 
extension are maintained by assistants, for the purpose of restoring the 
fragments to position if possible, the surgeon will apply a roller, in- 
closing the splints, from the elbow to the axillary margins. This roller 
must be carefully stitched to the covers of both splints. A second roller 
is then carried from the top of the long splint to the opposite axilla, and 
by several successive turns the upper end of the splint and the shoulder 
are completely covered in. This is also to be made fast to the cover of 
the long splint, by stitches. Finally, a third roller is made to inclose 
both the body and the lower portion of the arm ; and the forearm is 
secured at a right angle with the arm by a sling, looped under the fore- 
arm. It is important that the sling shall not embrace the elbow, since 
it will, if thus applied, tend to displace the fragments and drive them 
past each other. 

The bandage or roller hitherto applied by surgeons to the hand and 
forearm, when dressing a broken humerus, is wholly unnecessary and 
often a source of annoyance. The roller inclosing the arm and splints 
will seldom give rise to serious congestion or swelling of the forearm 
and hand unless it is applied too tightly ; and when swelling does occur 
it will be promptly relieved by a few hours' or days' confinement to the 
horizontal position. The most serious objection, however, to the roller 
applied to the hand and forearm, is not that it is unnecessary, but that 
it is, in most cases, injurious. It is exceeding liable to become dis- 
arranged, especially if the patient is permitted to move the arm at the 
elbow-joint ; and in most cases it will be soon found, by its unequal 
pressure, to cause those congestions and swellings which it was designed 
to prevent. Perhaps it will be sufficient for me to say that for many 
years I have rejected this bandage altogether in all fractures of the 
humerus, and that no harm has ever come of the practice. 

It will be readily seen that the first roller performs the most import- 
ant function in this dressing. The long outer splint being firm and 
unyielding, and being supported above by the projection of the head of 
the humerus, the first roller draws the upper end of the lower fragment 
outwards, and thus, as far as possible, accomplishes its readjustment 



SHAFT BELOW THE SURGICAL NECK. 259 

The upper fragment is always beyond our control. The second roller 
is not of much use, inasmuch as it soon becomes loose ; and in any event 
it can only hold the top of the splint a little more firmly against the 
head of the humerus. I occasionally omit it. The third roller insures 
quietude to the arm, in the best position, namely, beside the body. 

When the patient is standing or sitting, the forearm needs to be sus- 
pended in the sling ; but when reclining, the forearm may, if the patient 
choses, be extended. If the entire dressing is well stitched it is not 
much liable to disarrangement, and may be worn two or three weeks at 
a time without removal ; but from time to time, as the swelling subsides 
or the muscles atrophy, the bandages may need to be tightened by 
overstitching, or by supplementary rollers. 

I have been thus minute in my description of this dressing, because 
its value depends upon the care with which the details are carried out ; 
and because, essentially, the same dressing is used by me in all fractures 
of the humerus occurring through its upper or middle thirds ; moreover, 
I do not wish to be held responsible, in any case, for bad results when 
dressings are applied in an imperfect or slovenly manner. 

If union takes place without overlapping, of course the arm is not 
maimed by the fracture ; but even when the union occurs with consid- 
erable overlapping, the usefulness of the arm is seldom impaired. 

§ 5. Shaft, below the Surgical Neck and above the Base of the Condyles. 

Causes. — In a record of 36 cases in which the cause of the fracture 
is stated, I find this portion of the shaft broken from direct violence 
21 times ; from indirect blows, the concussion being received upon the 
elbow, 9 times; twice it was a consequence of tertiary lues, once it 
occurred during birth, and three times in the same patient it has been 
broken from muscular action alone, each consecutive fracture occurring 
at a different point. The records of surgery furnish many examples of 
fracture of the shaft of the humerus from muscular action, as in throw- 
ing a stone or snowball ; but the most singular examples are those in 
which the bone has been broken in a trial of strength between two 
persons, by grasping the hands palm to palm, with the elbows resting 
upon a table, and twisting, when the humerus has suddenly given way 
a little above the condyles. This practice is called by the French 
" tourner poignet" the game of turning wrists. I have seen one case 
of this kind, which was under the care of Dr. Winne, and Malgaigne 
has collected five other similar cases, two of which were reported by 
Lonsdale. In Z7 Union Medicale is reported an example in which the 
fracture occurred on a level with the insertion of the deltoid, a little 
below T the insertion of the pectoralis major and latissimus dorsi. The 
fracture seemed to be nearly transverse. 1 A case is also mentioned in 
the Canada Med. and Surg. Journ., 1875, the fracture occurring at 
about the same point. 

The example of fracture during birth, to which I have referred, 
occurred in a healthy female child, whose parents were also healthy. 

1 Amer. Med. Times, vol. iv. p. 153. 



260 FRACTURES OF THE HUMERUS. 

The mother was in labor six or eight hours, but the labor was not 
severe. She was attended by a midwife, and does not know whether 
violence was employed or not. Dr. Lockwood, of Buffalo, was called 
on the third day, and found the arm broken a little below its middle, 
and moving as freely as it did at the elbow-joint ; he applied lateral 
splints with bandages, etc. I saw the child with Dr. Lockwood on the 
seventeenth day after its birth. There was then a perfect ferrule of 
ensheathing callus surrounding the fragments, and which, owing to the 
softness of the flesh, could be easily detected and defined. The frag- 
ments had been firm at least three or four days. Nearly a year after, 
I again examined the arm, and could not discover any traces of the 
accident. 

Dr. Lowenhardt has also reported a case in which the evidence was 
conclusive that the fracture was caused solely by the contractions of the 
uterus, which forced the arm against the pubes ; the arm being heard 
distinctly to snap when it was passing this point and Avhile the hands 
of the accoucheur were not aiding in the delivery. In this case the 
humerus was broken in its upper third. 1 

Dr. N. Fanning, of Catskill, N. Y., has reported to me the following 
as having occurred in his own practice : — 

" Mrs. H., of Catskill, was delivered June 8, 1865, after a short and 
not severe labor, of a full-grown and healthy male child. The mother 
was well formed, with ample pelvis. The labor was natural, and the 
presentation the most favorable, the occiput corresponding to the left 
acetabulum ; but immediately after the delivery of the head, a hand 
and a portion of the forearm of the child were felt above the pubes. 
The shoulders and body were delivered very quickly after the head, 
and during a single pain. Just as the right shoulder of the child was 
passing under the arch of the pubes, I heard a snap, not unlike that 
caused by the breaking of a pipe-stem, which I soon found, as I sus- 
pected, to be caused by the fracture of the right os humeri of the child 
in its upper third." The bone united with some deformity. 

Dr. Fanning is of the opinion that, in this case, the contraction of 
the uterus, occurring while the arm of the child occupied some unusual 
position, was the cause of the fracture. It was certainly not due to any 
force applied by Dr. Fanning himself. 

Seat and Direction of the Fracture. — The seat of the fracture is more 
often below than above the middle of the bone ; thus, I have found the 
fracture fourteen times near the middle, and the same number of times 
below the middle third, but only seven times above the middle third. 
The observations of Norris, who found four fractures of the shaft above 
the middle, and nine below, correspond with my own ; 2 but M. Grueretin, 
in the same number of fractures, found nine above the middle and four 
below. 3 

The line of fracture is generally oblique, but more often transverse 
than in fractures of the clavicle, femur, or tibia. 

' Lowenliai-dt, American Journal of the Medical Sciences, January, 1841, p. 250, 
from Medicin, Zeit., Mai 6, 1840. 

2 Norris, Am. Journ. of Med. Sci., January, 1842, vol. xix. p. 28. 

3 Gueretin, Presse Medicale, vol. i. p. 45. 



SHAFT BELOW THE SURGICAL NECK. 261 

Displacement. — The direction of the displacement depends, no doubt, 
sometimes upon the precise point of the fracture and upon the action 
of the muscles operating upon the two fragments ; thus, if the fracture 
takes place just above the insertion of the deltoid, the lower fragment 
is liable to be drawn upwards and outwards, in the direction of its 
fibres, while the upper fragment is carried toward the origin of the 
pectoralis major, etc. ; but, in a great majority of cases, the influence 
of these muscles is more than counterbalanced by the direction of the 
force, and by the direction of the fracture. Practically, therefore, it is 
seldom of much importance to determine the exact point of fracture, 
as to whether it is just above or below the insertion of a particular 
muscle ; nor, indeed, is it generally very easy to ascertain this point 
with much precision. 

The amount of displacement varies considerably in different persons 
and in fractures at different points, but it will average about three- 
quarters of an inch. When the fracture is produced by muscular 
action alone, it is generally transverse, and displacement seldom occurs. 
Such was the fact in every instance where my own patient broke the 
arm three times consecutively at different points ; and union was 
speedily accomplished, and with no deformity. Dupuytren, however, 
saw a case which constituted an exception to this general rule. The 
fragments became completely separated, and were so movable that 
union could not be effected, and he was compelled, after three months, 
to resort to resection. 

The average shortening after these fractures, exclusive of those which 
do not shorten at all, seems to be about half an inch ; but a considerable 
number are never displaced, as the fractures are so nearly transverse 
that they are easily reduced and maintained in place, and consequently 
the total average of shortening is probably less than half an inch ; in a 
few cases it is much greater. Practically, the shortening is a matter of 
no importance. In the case of Margaret O'Brian, admitted to my ward, 
Bellevue Hospital, April 9, 1878, with a fracture of the humerus, near 
its middle, and treated w T ith my splint, the fragments united with a 
lengthening of half an inch. 

I have met with a number of examples of delayed and of fibrous union 
of this bone after a fracture (exclusive of gunshot fractures). In the 
first example of a complete failure the fracture was in the lower third of 
the shaft, oblique and compound, and no union had taken place at the 
end of five months. The man was intemperate, but in pretty good 
health. 1 In the second case, the fracture had occurred a little below 
the middle of the bone, and it was simple. Five months after the 
accident this patient consulted me, when I found the elbow anchylosed, 
the forearm being fixed at a right angle with the arm. 2 Neither of 
these patients had been under my care previously, but I learned that 
an intelligent Canadian surgeon had treated one of them, and the other 
had been seen and treated by several surgeons. 

In the third case, a lad, five years of age, received a fracture about 
three or four inches above the elbow-joint, by the passage across the 

1 Report on Deformities, etc., Case 33. 2 Ibid., Case 21. 



262 FRACTURES OF THE HUMERUS. 

limb of a heavy army wagon. The arm was dressed with splints, and 
in about five weeks several fragments of necrosed bone were removed 
by Dr. Pope, of St. Louis, and the splints were again applied. Ten 
months from the- date of the injury, Dr. Brinton, of Philadelphia, 
operated by perforation, and reapplied splints. When the splints were 
removed, the limb was straight and apparently firm, but the bond of 
union gradually gave way, and when he came under my charge in No- 
vember, 1864, more than two years after the accident, the arm was bent 
at an angle of 45°, and the union was fibrous only. Under my advice 
all restraint and dressings were removed, and he was sent into the 
country to improve his general health, with the understanding that I 
would operate at some future day. Subsequently, on the 14th of April, 
1867, 1 resected the bone at the seat of fracture, securing the fragments 
with wire, and supporting the arm with a gutta-percha splint. The 
result was a perfect bony union, and very useful arm. 

The fourth case is briefly as follows: Charles Cunz, get. about 35, 
broke his right arm a little below its middle, Oct. 29, 1876. He was 
placed under the care of an excellent physician, but, for some reason 
not satisfactorily explained, the fragments united only by fibrous tissue. 
March 25, 1877, five months after the fracture had occurred, I incised 
to the bone, and with an ordinary steel gimlet transfixed the overlapping 
fragments. Splints were then applied. The gimlet was permitted to 
remain six weeks, during which time it became quite loose, and an 
abscess formed below the wound. At the end of this time the bond of 
union was quite firm, but the splints were continued six weeks longer. 
At this date the union remains perfect, the humerus is straight, and the 
usefulness of his arm is unimpaired. 

In a fifth case, that of F. II. Fennell, of Pittston, Pa., set. 21, the 
right arm was broken below its middle, a simple fracture ; pasteboard 
and wooden angular splints were employed, but only a fibrous union 
took place. When he consulted me, eight months after the accident, 
the fragments remained ununited, and overlapped one inch. He was 
not prepared to submit to the treatment I proposed, namely, perforation 
of the fragments, and I have not heard from him since. 

Muhlenberg, in his tables of delayed union and ununited fractures of 
long bones, including Q36 cases, has recorded 219 of the humerus : of 
13 treated by manual friction, 4 were cured and 9 failed ; of 10 treated 
by mechanical appliances, 6 were cured, 3 relieved, and 1 failed ; of 42 
treated by seton, 12 were cured, 24 failed, and 1 died ; of 13 treated 
by immobilization, 5 were cured, 6 failed, and 1 died ; of 83 treated by 
resection, 43 were cured, 31 failed, 6 were relieved, 2 died, and in 1 the 
result is unknown; of 35 treated by drilling, 21 were cured, 2 were re- 
lieved, and 11 failed. 

In a few cases the elbow has remained somewhat stiff a long time 
after the splints were removed ; and in one case which was brought to 
my notice complete freedom of motion was not restored at the end of 
fifteen years. Generally, however, the motions of the elbow-joint have 
been very soon restored after the removal of the splints and sling. 

I ought to mention that, not unfrequently, fractures of the shaft of 
the humerus, and especially where they are occasioned by direct blows, 
are followed by great swelling, and sometimes by abscesses. In one 



SHAFT BELOW THE SURGICAL NECK. 



263 



Fig. 71. 



instance, the fracture having taken place within the insertion of the 
deltoid muscle, the sharp extremity of the lower fragment was made to 
penetrate the flesh, causing an abscess, and finally tetanus, of which my 
patient soon died. 

Dr. Lee writes to me, under date of Oct. 13, 1876, that a simple frac- 
ture of the lower third of the shaft, occurring in a child six years old, 
terminated in gangrene, and demanded amputation. Two other similar 
cases have been reported to me. In all of these cases a question arose 
as to the causes of the gangrene ; but the practice of the surgeons was 
sustained by the courts. 

Dec. 1, 1877, Peter Folan, set. 21, was admitted to Bellevue, with a 
fracture of the left humerus, near its middle. The fracture was caused 
by a fall from a wagon on the same clay. My splint was applied, and it 
was continued four weeks, when the fragments were found united, but he 
was discovered to have paralysis of the extensor muscles of the left hand 
and fingers. Two or three months later, their condition had much im- 
proved. The arm was perfectly straight. The bandage was never tight, 
and the cause of the paralysis was unexplained. 

Muhlenberg, in his tables of ununited fractures, has recorded 219 of 
the humerus, in a total of 656 of all of the long bones. 

The following remarks of Malgaigne are too pertinent to be omitted in 
this connection: " When there is great obliquity, with overlapping, or a 
fracture with splintering, or a multiple fracture, 
a certain amount of deformity is inevitable, and 
the formation of callus demands one or two weeks 
more. With the inflammation comes also the dan- 
ger of suppuration, and later, a rigidity of the 
articulations difficult to dissipate. In short, we 
must not forget that of all fractures, those of the 
humerus are most liable to fail of consolidation." 

On the other hand, we shall find, in the case 
of this bone, as in all others, some remarkable 
exceptions, where, although the fracture may be 
compound, and badly comminuted, yet the limb 
has been saved and made useful. 

Treatment. — In the treatment of fractures of 
that portion of the shaft of the humerus now 
under consideration, we shall do best to adopt 
essentially the same plan which I have recom- 
mended for fractures of the surgical neck. In 
proportion as the fracture occurs at a lower point 
of the humerus, however, will it be necessary to 
extend the long splint downwards, in the direc- 
tion of the elbow ; so that, while in fractures of 
the surgical neck and upper half of the shaft it 
may not be necessary to extend the splint quite 
as low as the external condyle, in the case of fractures in the lower half 
of the shaft it will be necessary to include the condyles with the splints, 
and sometimes it may be necessary to employ the gutta percha angular 
splint, which will be recommended hereafter in fractures involving the 




Lonsdale's extension appa- 
ratus.— A. Crutch. B. Shaft. 
C. Elbow rest. E. Hook for 
attachment of bandage, oppo- 
site which is a crossbar for the 
same purpose. 



264 



FRACTURES OF THE HUMERUS 



elbow-joint. It is in these latter cases, also, that we shall find, some- 
times, the plaster of Paris dressing, including the forearm, arm, and 
shoulder, giving the most satisfactory results : never neglecting, how- 
ever, when using this or any other form of immovable dressing, to observe 
the condition of the arm frequently as to the swelling or shrinkage. 
Whenever the splints are made to touch or include the condyles, very 
great care must be taken to protect them from pressure. 

Other surgeons have sought to make permanent extension in these and 
certain other fractures of the humerus, by various contrivances. Mr. 
Lonsdale constructed an instrument which might be lengthened or short- 
ened to suit the case ; it was made of steel, and was worked with a 
screw operating upon cogs in a sliding bar ; resembling, in some respects, 
the arm portion of Jarvis's adjuster. In the second London edition of 
a series of plates illustrating the action of the muscles in producing dis- 
placement in fractures, by S. W. Hind, is a drawing of an apparatus 
invented by the author for the same purpose, which is very simple, and 
in some respects more complete than Lonsdale's, and which may be 

easily adapted to almost any form of 
Fig. 72. arm-splint. Indeed, nothing more is 

necessary than to attach to the ordinary 
long splint a movable crutch. 

Dr. Henry A. Martin, of Boston, has 
invented a splint, also for the purpose of 
making extension in fractures of the hu- 
merus, the counter-extension being made, 
by adhesive plasters, from the side of the 
chest. The apparatus is elongated by a 
ratchet operating upon two steel bars, 
which are thus made to move upon each 
other. 

In my opinion, and in the opinion of 
nearly all practical surgeons Avho have 
written upon this subject, it is impossible 
by these or any other, similar contriv- 
ances to make extension in fractures of 
the humerus. The axilla can never be 
made a proper point of support for per- 
manent counter-extension ; and Dr. Mar- 
tin's method, while it avoids the dangers 
of axillary pressure, cannot prove ef- 
ficient. The adhesive plasters must in- 
evitably fail to retain their places when 
even a moderate amount of traction is 
continuously made upon them. 

The late Dr. E. A. Clark, of the St. 
Louis City Hospital, proposed to accom- 
plish the extension, in fractures of the head and surgical neck, by sus- 
pending a weight from the elbow. He reports one case successfully 
treated by this method ; and Dr. Tyndale, of New York, formerly his 
House Surgeon, informs me that several of the cases were treated in the 




Clark' 



extension in fractures of the neck 
of the humerus. 



SHAFT BELOW THE SURGICAL NECK. 265 

same manner, all of them being in the lower third of humerus. When 
the patient is in the recumbent posture, the weight must be suspended 
over a pulley. No doubt this is the only method by which really effec- 
tive extension can ever be made in fractures of the humerus. There may 
be, perhaps, examples of fractures of the neck of the humerus in which 
the fragments overlap persistently, where it will be proper to resort to 
this novel expedient. When fractures occur above the deltoid, the over- 
lapping is often excessive, and there is not much clanger of their being 
forcibly separated by the extension ; but in fractures below this, Dr. 
Clark's method might possibly expose to the danger of separation and 
non-union of the fragments, but it will be observed that this was the class 
of cases successfully treated by Dr. Clark. In the case of fractures of 
the neck, no splints are advised by Dr. Clark ; yet as a means of hold- 
ing the lower fragment out, a single outside splint might be useful. 

I have seen a case of compound fracture of the humerus treated by 
Dr. Stephen Smith, at Belle vue, in this manner, while the patient was 
confined to the bed, with the most satisfactory results ; and recently, in 
a case of fracture of the humerus, a little above the middle, complicated 
with other severe injuries, which eventually proved fatal, this method of 
extension was employed successfully by me, to prevent the violent spas- 
modic contractions of the muscles. In this case the arm and forearm 
were kept extended, the adhesive plaster extension strips being made fast 
to the hand and forearm, and the pulley and weight being arranged at 
the foot of the bed. 

In reference to those forms of apparatus which are intended to press 
upon the axillary margins, it ought to be stated here, since we have 
omitted to speak of it in connection with fractures of the surgical neck, 
that in all fractures of the upper half or third of the humerus, including 
fractures of the surgical neck, they must prove not only useless, but 
they must actually tend to defeat their own purpose. They are intended 
to replace the fragments ; but by their pressure upon the pectoralis major 
and latissimus clorsi, which compose the free margins of the axillary space, 
they must inevitably cause the separation of the fragments. 

Malgaigne, when speaking of the apparatus of Lonsdale, remarks: 
" But the surgeon should never lose sight of the fact that permanent 
extension is a resource always dangerous, often useless, and which de- 
mands in its application much caution and watchfulness." 

The following example will illustrate the practical difficulty of employ- 
ing permanent extension in fractures of the humerus : — 

A laborer, aged thirty, was admitted into the Buffalo Hospital of the 
Sisters of Charity, on the second day of October, 1853, with a simple 
oblique fracture of the humerus, which had occurred three days before. 
The fracture was situated within the insertion of the deltoid, and, having 
been produced by the rolling of a log upon the arm, the wdiole limb was 
much swollen. The night following his admission, in a fit of delirium 
tremens, he removed all of the dressings. When I visited the wards in 
the morning, I found the fragments displaced and the muscles contract- 
ing violently. The ordinary dressings were applied, and continued until 
the fifth day, when, as the delirium had not ceased, and the muscles 
continued to contract with great violence, it was determined to attempt 
18 



266 . FRACTURES OF THE HUMERUS. 

permanent extension. For this purpose we lifted the elbow upwards and 
outwards, to relax the deltoid, and then, having made extension with the 
forearm placed at a right angle with the arm, we fitted carefully a large 
gutta-percha splint to the forearm, arm, axilla, and side, in such a man- 
ner that when the splint was secured to these several parts, the arm could 
not fall to the side of the body completely, and in proportion as it did 
fall downwards, it would make extension upon the arm. This splint was 
well padded, and secured in place by rollers. 

On the sixth day the delirium had ceased, and never returned. The 
dressings were well in place, and seemed to accomplish the indication 
we had in view ; but, on the seventh day, although he had kept very 
quiet, everything was disarranged, and the whole had to be readjusted. 
On the eighth and ninth the same thing occurred. During. this time we 
had varied the dressings, position, etc., each day, to meet, if possible, 
the difficulties ; but it was at length deemed unwise to pursue the attempt 
any farther, and we returned to the use of the ordinary splints, laying 
the arm against the side of the body. The union was finally completed 
without either overlapping or angular displacement. I have no doubt 
now that we would have done much better if we had resorted to exten- 
sion, as practised by Dr. Clark. 

Something may always be accomplished, when the patient is walking 
about, by allowing the elbow to escape from the sling, so that its weight 
shall make constant traction upon the lower fragment ; and the plan 
which I suggested some years since, of treating certain cases of delayed 
union of the humerus, namely, extending the arm at full length by the 
side of the body, so that the lower fragment shall receive the whole 
weight of the forearm and hand, might occasionally prove valuable in 
recent fractures where the tendency to override was very great. 

The precise plan, and my reason for its adoption in certain cases of 
delayed union, were set forth in the following paper, read before the 
Buffalo City Medical Association, and published in the Buffalo Medical 
Journal for August, 1851. 

" I have observed that non-union results more frequently after frac- 
tures of the shaft of the humerus, than after fractures of the shaft of 
any other bone. 

" Comparing the humerus with the femur, between which, above all 
others, the circumstances of form, situation, etc., are most nearly paral- 
lel, and' in both of which non-union is said to be relatively frequent, I 
find that of forty-nine fractures of the humerus, four occurred through 
the surgical neck, twelve through the condyles, and twenty-nine through 
the shaft. In one of the twenty-nine the patient survived the accident 
only a few days. In four of the remaining twenty-eight union had not 
occurred after the lapse of six months, and in many more it was delayed 
beyond the usual time. Two of the four were simple fractures, and 
occurred near, the middle of the humerus ; the third was compound, and 
occurred near the middle also ; the fourth was compound, and occurred 
near the condyles. 

" This analysis supplies us, therefore, with four cases of non-union, 
from a table of twenty-eight cases of fractures through the shaft. 

" Of eighty-seven fractures of the femur, twenty occurred through 



SHAFT BELOW THE SUEGICAL NECK. 267 

the neck, one through the trochanter major, and one through the con- 
dyles. The remaining sixty-five occurred through the shaft, and gener- 
ally near the middle, and not in one case was the union delayed beyond 
six months. 

" To make the comparison more complete, I must add that of the 
twenty-eight fractures of the shaft of the humerus, six were compound ; 
and of the sixty-five fractures of the shaft of the femur, six were either 
compound, comminuted, or both compound and comminuted. The six 
compound fractures of the shaft of the humerus furnished two cases of 
non-union. The six cases of either compound or comminuted or com- 
pound and comminuted fractures of the femur, furnished no case of non- 
union. 

" I beg to suggest to the Society what seems to me to be the true ex- 
planation of these facts. 

" It is the universal practice, so far as I know, in dressing fractures of 
the humerus, to place the forearm at a right angle with the arm. Within 
a few days, and generally, I think, within a few hours, after the arm 
and forearm are placed in this position, a rigidity of the muscles and 
other structures has ensued, and to such a degree that if the splints and 
sling are completely removed, the elbow will remain flexed and firm ; 
nor will it be easy to straighten it. A temporary false anchylosis has 
occurred, and instead of motion at the elbow-joint, when the forearm is 
attempted to be straightened upon the arm, there is only motion at the 
seat of fracture. It will thus happen that every upward and downward 
movement of the forearm will inflict motion upon the fracture ; and in- 
asmuch as the elbow has become the pivot, the motion at the upper end 
of the lower fragment will be the greater in proportion to the distance 
of the fracture from the elbow-joint. 

" No doubt it is intended that the dressings shall prevent all motion of 
the forearm upon the arm ; but I fear that they cannot always be made 
to do this. I believe it is never done when the dressing is made without 
angular splints, nor is it by any means certain that it will be accomplished 
when such splints are used. The weight of the forearm is such, when 
placed at a right angle with the arm, and encumbered with splints and 
bandages, that even when supported by a sling, it settles heavily for- 
wards, and compels the arm-dressings to loosen themselves from the arm 
in front of the point of fracture, and to indent themselves in the skin 
and flesh behind. By these means the upper end of the lower fragment 
is tilted forwards. If the forearm should continue to drag upon the 
sling, nothing but a permanent forward displacement would probably re- 
sult. The bones might unite, yet with a deformity. 

" But the weight of the forearm under these circumstances is not uni- 
form, nor do I see how it can be made so. It is to the sling that we must 
trust mainly to accomplish this important indication. But you have all 
noticed that the tension or relaxation of the sling depends upon the at- 
titude of the body, whether standing or sitting ; upon the erection or 
inclination of the head ; upon the motions of the shoulders ; and in no 
inconsiderable degree upon the actions of respiration. Nor does the 
patient himself cease to add to these conditions by lifting the forearm 
with his opposite hand whenever provoked to it by a sense of fatigue. 



268 FRACTURES OF THE HUMERUS. 

" This difficulty of maintaining quiet apposition of the fragments while 
the arm is in this position, at whatever point it may be broken, becomes 
more and more serious as we depart from the elbow-joint, and would be 
at its maximum at the upper end of the humerus, were it not that here 
a mass of muscles, investing and adhering to the' bone, in some measure 
obviates the difficulty. Its true maximum is, therefore, near the mid- 
dle, where there is less muscular investment, and where, on the one hand, 
the fracture is sufficiently remote from the pivot or fulcrum to have the 
motion of the upper end of the lower fragment multiplied through a long 
arm, while on the other hand, it is sufficiently near the armpit and shoulder 
to prevent the upper portion of the splint and arm-dressings from obtain- 
ing a secure grasp upon the lower end of the upper fragment. 

" It must not be overlooked that the motion of whicli we speak belongs 
exclusively to the lower fragment, and that it is always in the same plane 
forwards and backwards, but especially that it is not a motion upon the 
fracture as upon a pivot, but a motion of one fragment to and from its 
fellow. This circumstance I regard as important to a right appreciation 
of the difficulty. Motion alone, I am fully convinced, does not so often 
prevent union as surgeons have generally believed. It is exceedingly 
rare to see a case of non-union of the clavicle. Of forty-seven cases of 
fracture of the clavicle which have come under my observation, and in 
by far the greater proportion of which considerable overlapping and con- 
sequent deformity ensued, only one has resulted in non-union, and in this 
instance no treatment whatever was practised, but from the time of the 
accident the patient continued to labor in the fields, and hold the plough 
as if nothing had occurred. I have, therefore, seen no case of non- 
union of the clavicle where a surgeon has treated the accident. Indeed, 
what is most pertinent and remarkable, its union is more speedy, usually, 
than that of any other bone in the body of the same size. Yet to pre- 
vent motion of the fragments in a case of fractured clavicle with com- 
plete separation and displacement, except where the fragment is near one 
of the extremities of the bone, I have always found wholly impracticable. 
Whatever bandage or apparatus has been applied, I have still seen always 
that the fragments would move freely upon each other at each act of in- 
spiration and expiration, and at almost every motion of the head, body, 
or upper extremities. It is probable, gentlemen, that you have made 
the same observation. 

" From this and many similar facts I have been led to suspect, for a 
long time, that motion has had less to do with non-union than was gene- 
rally believed. 

" I find, however, no difficulty in reconciling this suspicion with my 
doctrine in reference to the case in question ; and it is precisely because, 
as I have already explained, the motion, in case of a fractured humerus, 
dressed in the usual manner, is peculiar. 

" In a fracture of the clavicle through its middle third (its usual situ- 
ation), the motion is upon the point of the fracture as upon a pivot ; 
although, therefore, the motion is almost incessant, it does not essen- 
tially, if at all, disturb the adhesive process. The same is true in nearly 
all other fractures. The fragments move only upon themselves, and not 



SHAFT BELOW THE SURGICAL NECK. 269 

to and from each other. I know of no complete exception but in the 
case now under consideration. 

"Aside from any speculation, the facts are easily verified by a per- 
sonal examination of the patients during the first or second week of treat- 
ment, or at any time before union has occurred, both in fractures of the 
humerus and clavicle. The latter is always sufficiently exposed to per- 
mit you to see what occurs ; and as soon as the swelling has a little sub- 
sided in the former case, you will have no difficulty in feeling the motion 
outside of the dressings, or, perhaps, in introducing the finger under the 
dressings sufficiently far to reach the point of fracture. I believe you 
will not fail to recognize the difference in the motion between the two 
cases. Such, gentlemen, is the explanation which I wish to offer for the 
relative frequency of this very serious accident — non-union of the 
humerus. 

"I know of no other circumstance or condition in which this bone is 
peculiar, and which, therefore, might be invoked as an explanation. 
Overlapping of the bones, the cause assigned by some writers, is not 
sufficient, since it is not peculiar. The same occurs much oftener, and 
to a much greater extent, in fractures of the femur, and equally as often 
in fractures of .the clavicle, yet in neither case are these results so fre- 
quent. Nor can it be due to the action of the deltoid muscle, or of any 
other particular muscles about the arm, whether the fracture be below 
or above their insertions, since similar muscles, with similar attachments, 
on the femur and on the clavicle, tending always powerfully to the sepa- 
ration of the fragments, occasion deformity, but they seldom prevent 
union. 

" If I am correct in my views, we shall be able sometimes to consum- 
mate union of a fractured humerus where it is delayed, by straightening 
the forearm upon the arm, and confining them to this position. A 
straight splint, extending from the top of the shoulder to the hand, con- 
structed from some firm material, and made fast with rollers, will secure 
the requisite immobility to the fracture. The w r eight of the forearm 
and hand will only tend to keep the fragments in place, and if the splint 
and bandages are sufficiently tight, the motion occasioned by swinging 
the hand and forearm will be conveyed almost entirely to the shoulder- 
joint. Very little motion, indeed, can in this posture be communicated 
to the fragments, and what little is thus communicated is a motion, as 
experience has elsewhere shown, not disturbing or pernicious, but a 
motion only upon the ends of the fragments, as upon a pivot. 

" I do not fail to notice that this position has serious objections, and 
that it is liable to inconveniences which must always, probably, prevent 
its being adopted as the usual plan of treatment for fractured arms. It 
is more inconvenient to get up and lie down, or even to sit down, in this 
position of the arm, and the hand is liable to swell. But I shall not be 
surprised to learn that experience will prove these objections to have 
less weight than we are now disposed to give them. Remember, the 
practice is yet untried — if I except the case which I am about to relate, 
and in which case, I am free to say, these objections scarcely existed. 
The swelling of the hand was trivial, and only continued through the 



270 FRACTURES OF THE HUMERUS. 

first fortnight, and the patient never spoke of the inconvenience of get- 
ting up or sitting down, or even of lying down. 

"The following is the case to which I have just referred: ' Michael 
Mahar, laborer, set.' 35, broke his left humerus just below its middle, 
Dec. 14, 1858. The arm was dressed by a surgeon in Canada West, 
and who is well known to me as exceedingly " clever." After a few 
days from the time of the accident, " the starch bandage was put on as 
tight as it could be borne, and brought down on the forearm, so as to 
confine the motions of the elbow-joint." Six weeks after the injury, 
January 29, 1854, Mahar applied to me at the hospital. No union had 
occurred. The motion between the fragments was very free, so that 
they passed each other with an audible click. There was little or no 
swelling or soreness. In short, everything indicated that union was 
not likely to occur without operative interference. The elbow was com- 
pletely anchylosed. I explained to my students what seemed to me to 
be the cause of the delayed union, and declared to them that I did not 
intend to attempt to establish adhesive action until I had straightened 
the arm. They had just witnessed the failure of a precisely similar 
case, in which I had made the attempt to bring about union without pre- 
viously straightening the arm. 

" ' On the 6th of February, 1854, we had succeeded in making the 
arm nearly straight. I now punctured the upper end of the lower frag- 
ment with a small steel instrument, and, as well as I was able, thrust it 
between the fragments. Assisted by Dr. Boardman, I then applied a 
gutta percha splint from the top of the shoulder to the fingers, moulding 
it carefully to the whole of the back and sides of the limb, and securing 
it firmly with a paste roller. March 4th (not quite four weeks after the 
application of the splint) we opened the dressings for the second time, 
and carefully renewed them. A slight motion was yet perceptible be- 
tween the fragments. March 18th, Ave opened the dressings for the 
third time, and found the union complete. This was within less than 
forty days. The patient was now dismissed. On the 29th of April 
following, the bone was refractured. Mahar had been assisting to load 
the " tender" to a locomotive. As the train was just getting in motion, 
he was hanging to the tender by his sound arm, while another laborer 
seized upon his broken arm to keep himself upon the car, and with a 
violent and sudden pull wrenched him from the tender and reproduced 
the fracture. The next morning I applied the dressings as before, and 
did not remove them during three weeks ; at the end of which time the 
union was again complete. The splint was, however, reapplied, and has 
been continued to this time — a period of about six weeks.' " x 

Since the date of the above paper, I have several times had oppor- 
tunities to test the value of this mode of treatment in cases of delayed 
union of the humerus, and in each case with the same favorable result. 

Measurement. — It may be well to indicate in this place by what 
method we shall best insure an accurate measurement of the arm, or 
forearm. 

In either case, the point from which the measurement can be most 

1 Buffalo Med. Journ., vol. x. pp. 14-147. 



BASE OF THE CONDYLES. 271 

satisfactorily made above, is the posterior and inferior edge of the 
acromion process, at the most salient point of this margin, about oppo- 
site the scapuloclavicular articulation. If the arm can be straightened, 
the extremity of either of the fingers can be used as the lower fixed 
point. If the arm cannot be straightened, we may use as the lower 
point either condyle, or the point of the elbow. In order to get the 
point of the elbow accurately, the hands should be clasped in front of 
the body ; and as the elbows are pressed back, a rule may be laid be- 
neath, and the measurements made from the upper surface of the rule. 

§ 6. Base of the Condyles. 

Syn. — Supracondyloid Fractures of the Humerus. — Malgaigne. 

Causes. — Of 18 fractures at this point, 12 occurred in children under 
ten years of age, the youngest being two years old. 

In 11 cases the fracture had been produced by a fall, and it is pre- 
sumed that the blow was received upon the elbow ; in the remaining six 
cases the cause is not stated. I believe, therefore, that this fracture is 
generally the result of an indirect blow, inflicted upon the extremity of 
the elbow ; in a few examples it has been produced by a blow received 
directly upon the point of fracture, as by the kick of a horse, etc., but I 
have never, save in a single instance, been able to trace it to a fall upon 
the hand. Dr. Shearer, U. S. A., has reported a case also, which seem3 
to have occurred in the same manner. 1 

Fig. 73. 




Fractures at the base of the condyles. (From Gray.) 

Direction of the Fracture, Displacement, and Symptoms. — I think 
this fracture is generally oblique, and its line of direction upwards and 
backwards ; in nine of the eleven cases where this point was determined, 
such has been its apparent direction, and the lower fragment has been 
found drawn up behind the upper. Once I have found the lower frag- 
ment in front, and once on the outside of the upper. 

Three of the 18 were compound comminuted fractures, this being a 
larger proportion of serious complications than is usually found in con- 
nection with fractures of long bones. 

1 M. M. Shearer, Act. Asst. Surgeon, U. S. A. Boston Journ. of Chemistry, Feb. 
1, 1870. 



272 



FRACTURES OF THE HUMERUS. 



I have never met with what I supposed to be a separation of the lower 
epiphysis ; but surgical writers have occasionally spoken of this acci- 
dent, and the late Dr. Watson, of New York, believed that he had seen 
one example in aninfant not quite two years old. The limb had been 
violently wrenched by the mother, in attempting to lift her. She was 
not seen by Dr. Waston until the fourth day, at which time the swelling 
was such that the diagnosis could not be easily made out ; but on the 
ninth clay " it was apparent that the shaft of the humerus had been 
separated from its cartilaginous expansion at the condyles, near the el- 
bow." By the use of angular pasteboard splints the reduction was main- 
tained, and the fragments became united after about four or six weeks. 1 

Dr. J. C. Reeve, of Dayton, Ohio, has sent me a specimen of epiphy- 
seal separation, which occurred in his practice in the year 1864. A girl, 
set. 10, fell a few feet, striking, probably, upon her elbow. The frac- 
ture was compound, and union not having occurred at the end of three 
weeks, the condition of the arm rendered amputation necessary. In this 
case a small fragment of the shaft came away with the epiphysis. Drs. 
Little, Voss, and Buck, of this city, have each reported a similar case. 2 



Fig. 74. 



Fig. 75. 



Fig. 76. 




w#t%; 



Lower epiphysis. Dr. Eeeve's case of separa- 
tion of the lower epiphysis. 



Dr. Lange's case of separation of lower epiphy- 
sis, and detachment of epicondyles. 



The diagnosis of a fracture at the base of the condyles is attended 
with peculiar difficulties, and it has occasionally been mistaken for a dis- 
location of the radius and ulna backwards. Dupuytren says : " There 
is nothing so common as to see a fracture of the lower end of the hume- 



1 Watson, New York Journ. Med., Nov. 1853, p. 430, second series, vol. xi. 

2 Little, Voss, and Buck, New York Journ. Med., Nov. 1865, p. 133. 



BASE OF THE CONDYLES. 273 

rus, immediately above the elbow-joint, mistaken for a dislocation back- 
ward ;" and he mentions three cases w T hich have come under his own 
observation. I have found an opposite error, however, by far the most 
frequent, namely, a dislocation of both bones backwards has been sup- 
posed to be a fracture. 

The sources of this embarrassment are found in the proximity of the 
fracture to the joint, in the rapidity with which swelling occurs, and in 
the striking similarity of the symptoms which characterize the two acci- 
dents. 

It will be necessary, therefore, to establish with care the differential 
diagnosis. The following are the signs of fracture : — 

1. Preternatural mobility, which, owing to the rapidity of the swell- 
ing and the contraction of the muscles whose tendons are stretched over 
the projecting ends of the bones, is often soon lost, being succeeded, 
sometimes after a few hours, by a rigidity equal to that which is usually 
present in dislocations, or even greater. It is especially difficult to flex 
the arm, owing to the pressure by the upper fragment into the bend of 
the elbow. 

2. Crepitus. This can usually be detected at any period if the arm 
is sufficiently extended, so as to bring the broken surfaces again into 
apposition. 

3. When the extension is sufficient, reduction is easily effected, and 
the natural length of the arm is restored ; but the limb immediately 
shortens when the extension is discontinued — especially if at the same 
moment the elbow is bent. This is a very important means of diag- 
nosis. 

4. A careful measurement, made from the point of the internal con- 
dyle to the acromion process, declares a positive shortening of the 
humerus. 

5. By flexing and extending the forearm upon the arm, while the 
fingers are placed upon the lower portion of the humerus, the projecting 
fragments can be felt. Generally, the upper fragment being in front of 
the lower, and pressing down into the bend of the elbow, its end cannot 
be so easily recognized ; but the upper end of the lower fragment can 
easily be made out, posteriorly, when the forearm is considerably flexed. 
The lower end of the upper fragment feels more rough, and is less 
wide, than in dislocations. 

6. The whole of the lower fragment is carried backwards, and with 
it the radius and ulna, producing a striking prominence of the elbow 
and olecranon process. Efforts to straighten the forearm upon the arm, 
when no extension is used, increase rather than diminish this pro- 
jection. 

7. The forearm is slightly flexed upon the arm, the angle made at the 
elbow being 25 or 30 degrees. ' 

8. The hand and forearm are pronatecl. 

9. The relations of the olecranon process with the two condyles 
remain unchanged. 

In a case of epiphyseal separation, the lower end of the upper frag- 
ment has greater breadth than in the case of a fracture at the base of 
the condyle, and the line of separation is nearer the end of the bone. 



274 FRACTURES OF THE HUMERUS. 

Signs of a Dislocation of the Radius and Ulna Backwards. — 1. Pre- 
ternatural immobility. That is to say, extension and flexion are limited, 
but there is almost always present a preternatural lateral mobility. 

2. Absence of crepitus. It is in this joint especially that surgeons 
have been deceived by the chafing of the dislocated bones upon the in- 
flamed joint surfaces, and have supposed that they discovered crepitus 
when no fracture existed. The rapidity with which inflammation de- 
velops itself after dislocations of the elbow-joint, and the consequent 
abundant effusion of lymph, afford the probable explanation of this fre- 
quent error. 

3. When reduced, the bones are not generally disposed to become 
again displaced, even though the elbow should be flexed. 

4. The humerus is not shortened, but the olecranon process approaches 
the acromion process. 

5. There are no sharp projecting points of bone. The lower end of 
the humerus may not always be felt in the bend of the elbow ; but when 
it is felt, it is found to be relatively smooth, broad and round. 

6. A remarkable prominence of the elbow and olecranon process, 
which prominence is sensibly diminished when an effort is made to 
straighten the forearm on the arm. 

7. Forearm flexed upon the arm to about the same degree as in frac- 
ture. 

8. Hand and forearm pronated precisely as in fracture. 

9. Relations of the olecranon process to the condyles changed very 
greatly. 

The most constant diagnostic signs are, then, in the case of a fracture, 
crepitus, shortening of the humerus, projection of the sharp ends of the 
fragments, and an increase of the projection of the elbow when an 
attempt is made to straighten the arm ; and in the case of a dislocation, 
the absence of crepitus, humerus not shortened, while the olecranon 
approaches the acromion process ; the smooth, round head of the hu- 
merus lost, or indistinctly felt in the bend of the elboiv, and the pro- 
jection of the point of the elbow diminished when an attempt is made to 
straighten the forearm on the arm. 

It is proper, also, to repeat here what we have already said in rela- 
tion to the causes of this fracture. A fracture at this point is produced 
almost always by a fall upon the elbow, but a dislocation of the radius 
and ulna backwards can never be. On the other hand, a dislocation is 
produced, in most cases, by a fall upon the palm of the hand, while I 
have never known but one fracture above the condyles to be thus pro- 
duced. 

Results. — Nine times have I found the arm shortened from half an 
inch to one inch, or a little more. 

Muscular anchylosis is almost always present when the apparatus is 
first removed, and it is seldom completely dissipated until after several 
months ; but I have found more or less anchylosis at seven and nine 
months ; and twice after the lapse of three years the motions of the joint 
have been very limited. A few years since, I examined the arm of a 
gentleman who was then twenty -seven years old, and who informed me 
that when he was four years old he broke the humerus just above the 



BASE OF THE CONDYLES. 275 

condyles. There still remained a sensible deformity at the point of 
fracture — he could not completely supine the forearm. The whole arm 
was weak, and the ulnar nerve remarkably sensitive. The ulnar side 
of the forearm, and also the ring and little fingers, were numb, and have 
been in this condition ever since the accident. I know the surgeon very 
well who had charge of this case, and I have no doubt that the treatment 
was carefully and skilfully applied. 

In June of 1850, I operated upon a lad, nine years old, by sawing 
off the projecting end of the upper fragment, whose arm had been 
broken nine months before. This fragment was lying in front of the 
lower, and the skin covering its sharp point was very thin and tender. 
There was no anchylosis at the elbow-joint, but the hand was flexed 
forcibly upon the wrist, the first phalanges of all the fingers extended, 
and the second and third flexed. Supination and pronation of the fore- 
arm were lost. The forearm and hand were almost completely para- 
lyzed, but very painful at times. The ulnar nerve could be felt lying 
across the end of the bone. 

In the hope that some favorable change might result to the hand by 
relieving the pressure upon the nerve, yet with not much expectation of 
success, I exposed the bone and removed the projecting fragment. The 
nerve had to be lifted and laid aside. About one year from this time I 
found the arm in the same condition as before the operation. 

Non-union is a result not so frequent in fractures at this point as higher 
up ; but Stephen Smith, of the Bellevue Hospital, New York, reports a 
case of non-union in a young man of twenty-three years. He was ad- 
mitted to the hospital on the seventh day after the accident. The frac- 
ture was simple and transverse, yet at the end of four months he was 
dismissed "with perfectly free motion at the point of fracture." 1 The 
failure to unite was attributed to a syphilitic taint. 

A case was tried a few years since in the Supreme Court at Brooklyn, 
N. Y., in which, after a simple fracture at this point, the arm being 
dressed with splints and bandages, the little finger sloughed off in a con- 
dition of dry gangrene, and the adjacent parts of the hand were attacked 
with moist gangrene. Drs. Parker and Prince believed that this serious 
accident was the result of bandages applied too tightly and suffered to 
remain too long, while Drs. Valentine Mott, Rogers, Wood, Ayres, Dixon, 
and others, believed the gangrene might have been due to other causes 
over which the surgeon had no control. 2 

A few years ago, a similar case occurred in the town of Spencer, Tioga 
Co., N. Y.; a boy, six years old, having broken his humerus just above 
the condyles. The fracture was oblique. The surgeon who was called 
to treat the case was an old and highly respectable practitioner. I am 
not informed of the plan of treatment any farther than that a roller was 
applied. On the eighth day, a second surgeon was employed, who, finding 
the hand cold and insensible, removed all of the dressings ; after which 
the thumb and forefinger sloughed, with other portions of the skin and 
flesh of the hand and arm. The surgeon who was first in attendance 

1 Smith, New York Journal of Medicine, May. 1857, p. 386, third series, vol. ii. 

2 New York Medical Gazette, vol. xii. pp. 46,' 80, 111. 



276 FRACTURES OF THE HUMERUS. 

was prosecuted, and the case was tried in the Supreme Court of that 
county, but the jury found no cause of action. Dr. Hawley, of Ithaca, 
and the late Dr. Webster, of Geneva Medical College, testified that, in 
their opinion, the death of the fingers was owing to the pressure of the 
fragment upon the brachial artery, and not to the tightness of the band- 
ages. 

Dr. Gross has also informed us of still another case of the same char- 
acter, which occurred in Warren Co., Ky. A boy, ten years old, had 
broken his arm above the condyles, and his parents having employed a 
surgeon residing at some distance, the dressings were applied, and di- 
rections given to send for the surgeon whenever it became necessary. 
The parents saw the arm swell excessively, and knew that the boy was 
suffering very much, but did not notify the surgeon until the tenth day, 
when the hand was found to be in a condition of mortification, and at 
length amputation became necessary. 

Long afterward, in the year 1851, when the boy became of age, he 
prosecuted his surgeon, but with no result to either party beyond the 
payment of their respective costs. 

A similar case has been reported to me by Dr. Lyman Twomley, of 
Little Valley, Cattaraugus County, in this State. Dr. Twomley is a well- 
known and experienced surgeon and physician. In the fall of 1860, Dr. 
T. was called to a boy set. 7, who had fallen ten feet and broken his right 
arm at the base of the condyles. Although but twelve hours had elapsed, 
the limb was greatly swollen. The lower end of the upper fragment 
projected through the skin three inches. His pulse was feeble and in- 
termittent. Dr. T. administered chloroform and adjusted the fragments. 
Light splints were applied, and cold lotions. On the fifth day gangrene 
commenced, and on the seventh day Dr. T. amputated at the point of frac- 
ture. The wound resulted in the formation of a good stump. Examin- 
ing the limb after amputation, the joint was found filled with blood, in a 
putrid state, and the tissues above and below were infiltrated with the 
same. Both of the lateral and the anterior ligaments of the joint were 
badly torn. The biceps and brachialis anticus were much torn. A small 
portion of the olecranon process, and more of the coronoid processes were 
broken off. The brachial artery was ruptured, and the median nerve 
seriously injured. There was also a partial fracture of the carpal ex- 
tremity of the radius. 

When this boy became of age he entered a suit against the doctor for 
malpractice, in having, he affirmed, made an unnecessary amputation of 
the arm. I am informed that the allegations were not sustained by the 
Court, and in this decision all surgeons must heartily concur. 

While I would not deny that in some of the preceding cases the slough- 
ing might have been solely due to the tightness of the bandages, against 
which cruel and mischievous practice we cannot too strongly protest, a 
knowledge of the anatomy of these parts, and the opinions of the very 
distinguished gentlemen who testified in defence of these surgeons, must 
compel us to admit the possibility of such accidents where the treatment 
has been skilful and faultless. 

Treatment. — The splints formerly much employed in this country, in 
fractures about the elbow-joint, and perhaps still used by some American 



BASE OF THE CONDYLES 



surgeons, are simple angular side splints, without joints, such as those 
recommended by Physick: 1 angular pasteboard splints, felt, leather, 
gutta percha, etc., or angular splints with a hinge, such as Kirkbride's, 2 
Thomas Hewson's, Day's, Rose's, Welch's, or Bond's. 



Fig. 77. 



Fig. 78. 




Welch' 



splint. The hinges may he transferred to 
splints of different sizes. 



Kirkbride's splint, which is said to have been used in the Pennsylvania 
Hospital in several instances, is composed of two pieces of board, con- 
nected together by a circular joint, and having eyes on the inner edge, 
two inches apart, and holes through the splint at graduated distances be- 
tween them. There is also a swivel eye, passing through the upper part 
of the splint, and riveted below. A wire is fastened to the swivel, and 
bent at right angles at its other extremity, of a size to fit the eyes and 
holes in the splint. This splint, properly supported by pads, is to be 
placed either upon the outside or inside of the arm, and secured by 
rollers. When the angle is to be changed, the wire is unhooked and 
removed to another eye, or to some of the intermediate holes upon the 
side of the splint. Dr. Kirkbride reports two cases of fracture of the 
lower part of the humerus treated by this plan, one of which resulted 
in anchylosis, but the other was much more successful. 

H. Bond, of Philadelphia, has contrived a very ingenious splint for 
the elbow-joint, and which is designed also to afford a complete support 
to the forearm. 

For myself, I generally prefer a thick sheet of gutta-percha, moulded 
and applied accurately to the limb. It should be extended beyond the 
elbow to the wrist, so as to support the whole length of the arm, elbow, 



1 Elements of Surgery, hy John Syng Dorsey, Philadelphia edition, vol. i. p. 145. 

2 American Journal of the Medical Sciences, vol. xvi. p. 315. 



278 



FEACTURES OF THE HUMERUS 



and forearm. Some experience in the use of wooden angular splints has 
convinced me that they cannot be very well fitted to the many inequali- 
ties of the limb ; and neither pasteboard nor binder's board has sufficient 
firmness, especially in that portion which covers the joint. Angular 

Fig. 79. 




Bond's elbow splint. 



splints, furnished with a movable joint, possess the advantage of enabling 
us to change the angle of the limb at pleasure, and of keeping up some 
degree of motion in the articulation without disturbing the fracture or 

removing the dressings ; but the 



Fig. 80. 



crossbars 



of Day's and Rose's 
splints render them complicated, 
and are in the way of a nice appli- 
cation of the rollers ; while they 
are all equally liable to the objec- 
tion stated against angular wooden 
splints without joints, viz., that they 
seldom can be made to fit accu- 
rately the many irregularities of 
the arm, elbow, and forearm. In 
applying the author's splint, care 
must be taken that the humeral 
portion is not too short, or the re- 
sult will be an unnecessary degree 
of overlapping of the fragments. 
This may generally be avoided if 
the surgeon will first shape his ma- 
terial to the sound arm, while the 
whole length is underlaid with three 
or four thicknesses of woollen cloth. 
Welch's splints, made of a mate- 
rial possessing a slight amount of 
flexibility, approach more nearly 
the accomplishment of all the indications than any other manufactured 
splint with which I am acquainted, but the number of cases in practice 




The author's gutta-percha elbow splint. 



FRACTURE AT THE BASE OF THE CONDYLES. 279 

to which they are applicable will he found to be limited, while gutta- 
percha has no limit in its application. 

Whatever material is employed, the splint should be first lined w T ith 
one thickness of woollen cloth, or some proper substitute. A pretty 
large pledget of fine cotton batting ought also to be laid in front of 
the elbow-joint, to prevent the roller from excoriating the delicate and 
inflamed skin ; and great care should be taken to protect the bony emi- 
nences about the joint, or, rather, to relieve them from pressure, by 
increasing the thickness of the pads above and below these eminences. 

At a very early day, so early, indeed, as the seventh or eighth 
day, the splint should be removed, and, while the fragments are 
steadied, the joint should be subjected to gentle, passive motion. This 
practice should be repeated as often as every second or third day, 
in order to prevent, as far as possible, anchylosis. If much swelling 
follows the injury, it is my custom to open the dressings, without re- 
moving the splints, on the second or third day after the accident, or at 
any time when the symptoms admonish of its necessity. Occasionally 
it is well to change the angle of the splint before reapplying it. If the 
angular splint with a movable joint is used, slight changes may be made 
while the splint is on the arm ; but if the angle is much changed without 
removing the rollers, they become unequally tightened over the arm, and 
may do mischief. 

When anchylosis has actually taken place, we may more or less over- 
come the contraction of the muscles and of the ligaments by gentle, pas- 
sive motion, or by directing the patient to swing a dumb bell or some 
other heavy weight, as first recommended by Hildanus ; but we must 
bear in mind the danger of causing a refracture by too early or immode- 
rate force. 

§ 7. Fracture at the Base of the Condyles, complicated with Fracture between 
the Condyles, extending into the joint. 

This fracture, which is but a variety or complication of the preceding, 
is even more difficult of diagnosis ; and its signs, 
results, and proper treatment differ sufficiently to Fig. 81. 

demand a separate consideration. 

I have recognized the accident six times. 
Confined to no period of life, it seems to be 
the result of a severe blow inflicted directly upon 
the lower and back part of the humerus, or upon 
the olecranon process. Dr. Parker, of New York, 
was inclined to regard an obscure accident about 
the elbow-joint, which he saw in a lad sixteen 
years old, as a longitudinal fracture of the hume- 
rus, with separation of one condyle, but which 
had been occasioned by a fall upon the hand. 1 

For myself, I should regard this latter circum- Fracture at the base of, and 
stance as presumptive evidence that it was not a between, the condyles. 

1 Parker New York Journal of Medicine, Nov. 1856, p. 391, 3d series, vol. i. 




280 FRACTURES OF THE HUMERUS. 

fracture of this character, yet I do not mean to deny the possibility of 
its occurrence in this way. 

Its characteristic symptoms are, increased breadth of the lower end 
of the humerus, Occasioned by a separation of the condyles ; displace- 
ment upwards and backwards of the radius and ulna ; shortening of the 
humerus ; crepitus and mobility at the base of the condyles, with crepitus 
also between the condyles, developed by pressing them together ; or in 
case the radius and ulna are drawn up and back, the crepitus may be 
detected, after restoring these bones to place, by pressing upon the oppo- 
site condyles. 

Its consequences are, generally great inflammation about the joint, 
permanent deformity and bony anchylosis. An opposite result must be 
regarded as fortunate, and as an exception to the rule. 

Of the treatment we can only say that it must be chiefly directed to 
the prevention and reduction of inflammation ; at least during the first 
few days. Nor is this inconsistent with an early reduction of the frag- 
ments, and moderate efforts, by splints and bandages, such as we have 
directed in case of a simple fracture at the base of the condyles, to keep 
the fragments in place. No surgeon would be justified in refusing alto- 
gether to make suitable attempts to accomplish these important indica- 
tions ; but he must always regard them as secondary when compared 
with the importance of controlling the inflammation. 

When splints are employed, the same rules will be applicable, both as 
to their form and mode of application, as in cases of simple fracture 
above the condyles. Plaster of Paris, or some of the immovable forms 
of dressing, furnished with ample fenestra, will sometimes be preferred. 

The following examples will more completely illustrate the character, 
history, and proper treatment of these cases than any remarks or rules 
which we can at present make. 

A woman, set. 44, fell upon the sidewalk in January, 1850, striking 
upon her right elbow. I saw her a few minutes after the accident, but 
the parts about the joint were already considerably swollen, and it was 
not without difficulty that the diagnosis was made out. The forearm 
was slightly flexed upon the arm, and pronated. On seizing the elbow 
firmly, a distinct motion was perceived above the condyles, and a crepi- 
tus. I could also feel, indistinctly, the point of the upper fragment. 
While moderate extension was made upon the arm, the condyles were 
pressed together, when it was apparent that they had been separated. 
On removing the extension, they again separated, and the olecranon drew 
up. She was in a condition of extreme exhaustion, and the bones were 
easily placed in position. 

An angular splint was secured to the limb, and every care used to 
support the fragments completely, but gently. 

From this date until the conclusion of the treatment the dressings 
were removed often, and the elbow moved as much as it was possible to 
move it. 

Seven months after the accident, the elbow was almost completely an- 
chylosed at a right angle. The fingers and wrist, also, were quite rigid. 
Six years later, the anchylosis had nearly disappeared ; she could now 
flex and extend the arm almost as much as the other ; the wrist-joint 



FKACTUKE AT THE BASE OF THE CONDYLES. 281 

was free, and the fingers could be flexed, but not sufficiently to touch 
the palm of the hand. The line of fracture through the base could be 
traced easily, but the humerus was not shortened. There was, more- 
over, much tenderness over the point of fracture through the base, and 
at other points. Occasionally, a slight grating was noticed in the 
radio-humeral articulation. She experienced frequent pains in the arm, 
and especially along the back and radial border of the ring finger. 
During the first } T ear or two after the accident, the arm wasted very 
much, but although the hand remained weak, the muscles were now well 
developed. 

A gentleman was struck with the tongue of a carriage with which a 
couple of horses were running. The blow was received directly upon 
the back of the left elbow. Dr. Sprague and myself removed some small 
fragments of bone, and while opening the wound for this purpose, we 
could see distinctly the line of fracture extending into the joint as well 
as across the bone. The condyles were not separated. 

The subsequent treatment consisted only in the use of such means as 
would best support the limb, and most successfully combat inflammation. 
The arm and forearm were laid upon a broad and well-cushioned angular 
splint, covered with oil cloth, to which they were fastened by a few light 
turns of a roller. 

Twelve years after, I found the humerus shortened one inch and a 
half. During the first year, he says, there was no motion in the elbow- 
joint, but he can now flex and extend the forearm through about 45° ; 
when flexed to a right angle, it seems to strike a solid body like bone. 
Rotation of the forearm is completely lost, the hand being in a position 
midway between supination and pronation. He suffers no pain, and his 
arm is quite strong and useful. No means have been employed to re- 
store the functions of the limb but passive motion at first, and subse- 
quently constant, active use of the hand and arm. 

The late Dr. Thomas Spencer, of Geneva, used to relate a case in 
which a surgeon was called to what he supposed to be a fracture of the 
lower end of the humerus, and which he treated accordingly, with 
splints, etc. On the second or third day, another surgeon was called, 
who removed the splints and bandages, and pronounced it a dislocation 
of the radius and ulna backwards ; but he was unable to reduce it. 

After some time, the first surgeon was prosecuted for having treated 
as a fracture w r hat proved to be a dislocation. Dr. Spencer, who had 
examined the arm carefully, gave his testimony last, and at a time when, 
from the evidence, it seemed almost certain that the surgeon must be 
mulcted in heavy damages ; but he declared his belief that both surgeons 
were right, since, on measuring the breadth of the humerus through its 
two condyles, he found that the humerus of the injured arm was three- 
quarters of an inch wider than the opposite. His conclusion, therefore, 
was that the condyles had been split asunder and were now separated ; 
that the first surgeon properly reduced this fracture, but that when, on 
the second or third day, the second surgeon removed the splints and the 
dressings, a contraction of the muscles had taken place and the disloca- 
tion occurred, the bones of the forearm being drawn up between the 
fragments. Dr. Spencer believed this was an example of the variety of 
19 



282 FRACTURES OF THE HUMERUS. 

fractures now under consideration, but it is not quite certain that there 
was anything more than an oblique fracture extending into the joint, fol- 
lowed by a dislocation. In either case, the first surgeon was entitled to 
an acquittal, and so the jury promptly declared by their verdict. 

Although the flexed position must usually be regarded as the best in 
these fractures, for the reason that it most completely relaxes the bi- 
ceps, brachialis anticus, and the flexors of the forearm, and because if 
anchylosis ensues the flexed position gives the most useful arm, yet I 
think it might be proper to try what better may be accomplished by 
permanent extension, with the forearm straightened upon the arm, ac- 
cording to the method of Dr. Clark, described in the preceding pages. 

In a case of compound comminuted fracture of the character now under 
consideration, Dr. Stone, of the Bellevue Hospital, New York, removed 
the condyles and sawed off the sharp end. of the humerus. The woman 
was twenty-six years old and intemperate. The operation was made as 
a substitute for amputation. No serious complications followed. On 
the ninety-sixth day the wounds were completely healed, and she could 
bend the forearm to a right angle with the arm, the action of the muscles 
having drawn up the radius and ulna against the lower end of the shaft 
of the humerus, so that the motions were natural and free. 1 The prac- 
tice, as the result sufficiently shows, was eminently judicious ; and its 
practicability ought always to be well considered before resorting to the 
serious mutilation of amputation. The great principle upon which the 
success of resection is here based is the shortening of the bone, whereby 
the reduction may be accomplished without painful tension to the muscles ; 
a principle which will demand of us hereafter a more careful consider- 
ation and a wider application. 

Fractures and Diastases of the Condyles and HJpicondyles. 

Chaussier described that portion of the lower end of the humerus 
which articulates with the ulna as the trochlea, and that portion which 
articulates with the radius as the condyle ; naming the two lateral 
projections, respectively, epitrochlea and epicondyle. Some of the 
French writers have adopted this nomenclature, but I prefer, as being 
more familiar to my own countrymen, the terms external and internal 
condyles, to which it will be convenient to add the terms external epi- 
condyle and internal epicondyle, as indicating the abrupt lateral projec- 
tions on either side of the condyles, of which the largest portions are 
epiphyseal. These crests or projections are formed in part by a pro- 
longation of the outer and inner elevated margins of the humerus, 
and in part from separate centres of ossification, which in early life 
mainly overlie the two sides of the lower epiphysis. In advancing years 
these lateral epiphyses prolong themselves upwards to reach and par- 
tially overlie the humeral portions : the outer epiphysis becomes united 
by bony tissue to the shaft or humeral apophysis, about the sixteenth or 
seventeenth year; while the inner epiphysis, much larger than the outer, 
is not united usually to its corresponding apophysis until the eighteenth 

1 Stone, New York Journ. of Med., May, 1851, p. 302, vol. vi. 2d series. 



FRACTURES OF THE INTERNAL EPICONDYLE. 283 

year. Gurlt places the period of union of both of these epiphyses a 
year or two later. 

I shall hereafter speak of the epiconclyles as all of those portions of 
the lower end of the humerus which project abruptly from the condyles, 
and are composed in large part of the lateral epiphyses, but not entirely. 
Practically this definition leaves no portion of the lower extremity of 
the humerus outside of the capsule except the epicondyles. I say 
"practically," because it leaves no portion outside except the epicon- 
dyles which could possibly be broken off by an external or traumatic 
injury. We shall therefore have to speak only of fractures of the epi- 
condyles, and of fractures of the condyles involving the joint: the con- 
dyles proper, as distinguished from the epicondyles, constituting on the 
one hand the outer end of the lower extremity of the humerus, including 
so much of the articular surface as belongs to the eminentia capitata ; and 
on the other hand so much of the inner portion of the articular surface 
as includes the trochlea. 

As the reader will see hereafter, the epicondylar separations con- 
sist of two varieties, one of which is an epiphyseal separation, and the 
other a true fracture : one of which includes only a portion of the epi- 
condyle, and the other includes the whole. The remaining fractures 
will all be intracapsular. 

§ 8. Fracture of the Internal Epicondyle ; and Fracture or Diastasis of the 
Internal Epicondylar Epiphysis. 

I will here add, to what I have already said in the preceding pages of 
the anatomy and development of the humerus, the very careful descrip- 
tion of the development of the lower end of the humerus given by Dr. 
Zuckerkandl, Demonstrator of Anatomy in the University of Vienna. 1 

" The inferior extremity of the humerus proceeds from a synostosis of 
five saparately-developed portions of bone. These are : 1st, the hume- 
ral diaphysis, which includes the supratrochlear fossa, a minute portion 
of the eminentia capitata, and on the dorsal surface the ribbon-like zone 
of the trochlea ; 2d, the trochlea ; 3d, the eminentia capitata ; 4th and 
5th, the epicondyles. On the fully-formed humerus that part is called 
the internal epicondyle which projects lever-like above the trochlea, and 
serves as the point of origin of the flexor group. Though this bony 
prominence presents itself as a united whole at this stage, still an exami- 
nation of the humerus, in the earlier periods of its development, teaches 
us, that the internal epicondyle of the adult consists of two pieces, the 
superior of which belongs to the humeral diaphysis, to the median sur- 
face of which the osseous nucleus of the epicondyle applies itself, 
enlarges, and finally unites with the upper portion to form the lever of 
the flexor group of muscles. Accordingly what, in ordinary acceptation, 
is called a fracture of the epicondyle is something more, since it includes 
also a part of the humerus. It is difficult to believe, that only that part 

1 Zuckerkandl, on the Epicondylar Fracture of the Humerus. Hosp. Gazette, 
Sept. 27, 1879. Separat-Abdruck aus der "Algem. Wiener Mediz. Zeitung," 1878, 
Nr. 9. 



284 FRACTURES OF THE HUMERUS. 

of the internal epicondyle, which corresponds to the epiphyseal centre of 
ossification, should be broken off in the adult, so that distinct cases of 
epicondylar fracture can occur only in youthful persons. 

" What we call external epicondyle, on the completely-developed 
humerus, and a small portion of which (called ' la petite saillie,' in the 
above quotation from Malgaigne) can be felt and seen through the skin 
of the arm in lean subjects, belongs, as taught by embryological obser- 
vation, not properly to the external epicondyle, but represents the most 
inferior prominence of the crista externa humeri, with which the more 
posteriorly-extending epiphyseal nucleus of the external epicondyle 
finally unites. The epicondyles of adults, therefore, belong partly to 
the humerus and partly to the actual epiphyseal epicondyles, as a glance 
at the humeri of young persons teaches us. From the real internal 
epicondyle, which we term epiphyseal, arise the radialis internus, ulnaris 
internus, palmaris longus, and a small portion of the pronator teres, while 
from that part of the epicondyle, which belongs to the humeral diaphy- 
sis, arises the greater portion of the pronator above named. On the 
external epiphyseal epicondyle are found the common extensor of the 
fingers, the ulnaris externus, and the anconeus quartus." 

These views of the anatomy and development of the condyles and 
epicondyles, and which are no doubt correct, compel us to reconsider 
the statements we have made in previous editions of this work, and to 
correct certain errors into which the author in common with all other 
writers has fallen in the classification of certain reported examples of 
fractures of the epicondyles. Hitherto, while, in speaking of fractures 
of the internal epicondyle, I have distinctly stated that my remarks were 
limited to separations of the epicondylar epiphyses, I have not hesitated 
to include as proper examples those cases in which I believed the entire 
epicondylar projection to be included. Other writers have, without 
exception so far as I know, done the same. The observations of Zuck- 
erkandl, however, show that, as I have before stated, these extreme pro- 
jections are composed only in part of the true epicondylar epiphyses. 
We must then hereafter speak of those separations which are epicon- 
dylar, and only epiphyseal, as composing one class of accidents, and 
which must be in a great measure peculiar to children ; and of those 
which are epicondylar, but include also that portion of the epicondyle 
which is not epiphyseal, as another class, belonging chiefly to adults, but 
possible in children. 

According to Zuckerkandl it has been observed by Rambaud and 
Renault that there is sometimes a persistence of the epiphysis, the sepa- 
ration continuing to adult life ; from which we must infer that an epi- 
condylar epiphyseal diastasis might take place in the adult, but it must 
nevertheless be very infrequent. We can have, usually, no means of 
determining this point except in autopsy, and we must therefore be left 
in doubt sometimes whether a particular clinical case is to be regarded 
as an epiphyseal separation or a true fracture : our only means of dif- 
ferential diagnosis being the probabilities afforded by the age of the 
patient, the cause, and the size and form of the fragment. 

In treating of this subject then we can only relieve ourselves of the 
embarrassment by treating of epicondylar fractures and diastases as a 



FRACTURES OF THE INTERNAL EPICONDYLE. 285 

class, existing in two subordinate forms — namely, one in which only the 
epiphysis is torn off before bony union to the crista humeri has taken 
place — a true diastasis ; and the second, in which, bony union having 
been completed, the whole of the extreme projection or epicondyle is 
separated from the shaft — a true fracture. 
We shall consider first — 

Diastasis of the Epiphyseal Portion of the Internal Epicondyle. 

This we understand to be the accident which Granger first described, 
and which he ascribed solely to muscular action. He does not speak of 
it, however, as a diastasis of the epicondyle, but as " a particular frac- 
ture of the internal condyle." 

" A distinguishing circumstance attending this fracture," says Mr. 
Granger, "is that of its being occasioned by sudden and violent muscu- 
lar exertion ; and it will be recollected that from the inner condyle those 
powerful muscles which constitute the bulk of the fleshy substance of the 
ulnar aspect of the forearm have their principal origin. The way in 
which the muscles of the inner condyle are involuntarily thrown into 
such sudden and excessive action I take to be this : the endeavor to pre- 
vent a fall by stretching out the arm, and thus receiving the percussion 
from the weight of the body on the hand." 1 

It is a fact of significance in this connection, that most of these frac- 
tures hitherto reported as epicondylar have occurred in children, before 
the union of the epiphysis is completed, when muscular contraction 
might more often prove adequate to its separation, and when the epicon- 
dyle is less prominent, and, therefore, less exposed to direct blows than 
in adult life ; thus, of five fractures which I have regarded as fractures 
of the epicondyle, all, except one, occurred between the ages of two 
and fifteen years. But then it is equally true that a large majority of 
all the fractures of the internal condyle, including those which enter the 
articulation, as well as those which do not, belong to childhood and 
youth. I have seen but two exceptions in fifteen cases. Since, then, 
direct blows generally produce those fractures which penetrate the joint, 
no good reason can be shown why they should not sometimes produce 
fractures of the epicondyle. One of the exceptions to which I have 
referred as not having occurred in early life, is sufficiently rare to 
entitle it to especial notice. 

On the 16th of May, 1856, a laborer, thirty-four years of age, fell 
from an awning upon the sidewalk, dislocating the radius and ulna 
backwards ; the dislocation was immediately reduced by a woman who 
came to his assistance, but when he called on me soon after, I found a 
small fragment of the inner condyle, probably the epicondyle alone, 
broken off and quite movable under the finger. It was slightly displaced 
in the direction of the hand. 

I could not learn positively whether in falling he struck the elbow or 

1 "Ona Particular Fracture of the Inner Condyle of the Humerus," by Benjamin 
Granger, Surgeon, Barton-upon-Trent. Edinburgh Med. and Surg. Journ., vol. xiv. 
p. 196, April, 1818. 



286 FRACTURES OF THE HUMERUS. 

the hand, but there was presumptive evidence that he struck the hand ; 
if so, then probably the fracture was the result of muscular action, which 
is the more extraordinary as having taken place in a man of his age, but 
in which case it must be assumed that the epiphyseal union was delayed. 

It is pretty certain, however, that the theory of causation adopted by 
Granger is too exclusive.. A lad was brought to me in October, 1848, 
aged eleven, who had just fallen upon his elbow, the blow having been 
received, as he affirmed, and as the ecchymosis showed pretty conclu- 
sively, directly upon the inner condyle. The fragment was quite loose, 
and crepitus was distinct. He could flex and extend the arm, and rotate 
the forearm, without pain or inconvenience. I am quite sure the frac- 
ture did not extend into the joint ; the result seemed also to confirm this 
opinion, for in three months from the time of the accident the motions 
of the elbow-joint were almost completely restored. 

Indeed, Mr. Granger has failed to establish, by any particular proofs, 
that in more than one or two of his cases the fracture was the result of 
muscular action ; but, on the contrary, I am disposed to infer, from the 
violent inflammation which generally ensued in his cases, from the fre- 
quency of ecchymosis, and especially from the injury done to the ulnar 
nerve in at least three instances, that most of them were produced by 
direct blows inflicted from below in the fall upon the ground. Frac- 
tures produced by muscular action are seldom accompanied with much 
inflammation or effusion of blood, and it is much more probable that 
the ulnar nerve should have been maimed by the direct blow which 
caused the fracture, than by the displacement of the epiphysis, which 
is, as we shall presently show, almost always carried downwards, and 
oftener slightly forwards than backwards. It is only when the frag- 
ment is forced directly backwards that the ulnar nerve could be made 
to suffer ; a direction which, it does not seem to me, it could ever take 
from muscular action alone. 

Of all the cases above alluded to, including Granger's cases, it may be 
justly said that they were not verified by an autopsy, and that they do 
not therefore prove absolutely the existence of such a diastasis. 

Malgaigne speaks of this accident as a u fracture of the epitrochlea;" 
evidently including in this term all of the epicondylar projection. He 
states, however, that " there is good ground for supposing that, in some 
cases at least, it is a disjunction of the epiphysis." Gurlt distinctly 
states also that clinical experience shows that both the inner and outer 
epiphyses are sometimes broken, however difficult it may be to demon- 
strate the fact anatomically. The case of which he furnishes an illustra- 
tion in his book (p. 797, Fig. 109), and as being in the pathological 
collection at Wiirzburg, may indeed have been a fracture of the entire 
internal epicondyle, including both the epiphysis and the apophysis, but 
there is no evidence or pretence that it was the epiphysis alone. 1 

The specimen described by Zuckerkandl, found in the dissecting-room, 
and without a clinical history (Fig. 82), and which he has kindly sent 
to me, is probably the only example of which we can speak with any 

1 Handbuch der lehre von den Knochenbriichen. Von Dr. E. Gurlt, Prof, der 
Chirurgie an der Koniglichen Universitat zu Berlin. Hamm, 1862, pp. 796, 7. 



FRACTURES OF THE INTERNAL EPICONDYLE. 



287 



degree of positiveness as having been sustained by an autopsy. The 
following is his account of the specimen: — 

" The separation of the internal epicondyle I found on the left arm of 
the strong-boned man. After the removal of the flexors, the epicondyle 
appeared projecting forwards tumor-like, but immovable, so that at first 
sight I thought of a fracture healed by callus. As I removed the dense 
connective tissue, which surrounded the epicondyle, there appeared a 
furrow, which encircled the irregular bony prominence, and formed a 
sharp line of demarcation between it and the humeral epicondyle. The 
tumor-like bony prominence, therefore, represented the epiphyseal epi- 
condyle. On farther examination it was seen that the epiphyseal was 
connected with the humeral epi- 
condyle only by dense tissue, was 
irregularly formed on its uneven 
upper surface, slightly concave 
on its superior attached side, and 
of about the size of an os lunatum. 

" In the figure is plainly seen 
the intact humeral epicondyle, 
the epiphyseal epicondyle, and 
between them the above-described 
furrow, which was filled with 
fibrous tissue. The separated 
epicondyle does not correspond 
in form to that of a youthful per- 
son, nor to the inferior part of the 
flexor condyle in the adult. Its 
long axis in the latter is parallel 
with that of the humerus — in our 
preparation, however, it is sagit- 
tal, twisted, as it were, on its axis. 
The inferior portion of the epicondyle is in the adult about one-half cm. 
distant from the edge of the trochlea, but it is more than one cm. re- 
moved in this preparation ; so that the lateral surface of the trochlea is 
very deep." 

The bone is from an adult, as stated by Dr. Zuckerkandl, but he has 
omitted to mention that the coronoid fossa is small, and the olecranon 
fossa is nearly obliterated, indicating that for a long time before death 
the motions of the joint were limited. The nresuraption is, therefore, 
that this was an old fracture ; a fact which increases greatly the diffi- 
culty of determining precisely the original character of the accident. 

There is a broad vertical and remarkable facet mentioned by Dr. 
Zuckerkandl on the inner side of the trochlea ; the outer condyle is 
probably not normal in its shape, and altogether there are indications 
that the bone has at some time suffered a very severe and perhaps com- 
plicated injury. Perhaps there was more than one line of fracture ; 
possibly a transverse fracture through the shaft at the base of the con- 
dyles, or through the line of the epiphyseal junction. If such were the 
fact, the specimen does not illustrate a simple fracture of the epicondyle ; 




Separation of the epiphyseal portion of the internal 
epicondyle. (Zuckerkandl's specimen.) 



288 FRACTURES OF THE HUMERUS. 

but these are points which the ancient character of the fracture does not 
permit us to determine positively. 

We think, however, this may properly be called a separation of the 
epiphyseal portion of the internal epicondyle, but whether it was a 
simple fracture or separation, uncomplicated with any other lesion of the 
bone, cannot now be determined. 

Direction of Displacement, Symptoms, etc. — I have seen what I 
supposed to be this epiphysis displaced in the direction of the hand, or 
downwards, very manifestly, twice, and in two other examples a careful 
measurement showed a slight displacement in the same direction. The 
greatest displacement occurred in a boy fifteen years old, who was 
brought to me from St. Catharine, Canada West. He had fallen upon 
his arm in wrestling, and his surgeon found a dislocation of the bones of 
the elbow-joint, which he immediately reduced. The diastasis of the 
epicondyle was not at that time detected, the arm being greatly swollen. 
No splints were applied. It was three months after the accident when 
I saw him, at which time I found the internal epicondyle removed 
downwards toward the hand one inch and a quarter ; and at this point 
it had become immovably fixed. Partial anchylosis existed at the elbow- 
joint, but pronation and supination w T ere perfect. 

In one instance I believed the fragment to be carried about three 
lines upwards and two backwards toward the olecranon ; in each of the 
other examples the fragment did not seem to be displaced. 

Granger found, also, in the five examples which came under his notice, 
the epicondyle carried toward the hand, with more or less variation in 
its lateral position, so that while in some instances it touched the olecra- 
non, in others it was removed an inch or more in the opposite direction. 

It is probable that, except where controlled by the force and direction 
of the blow, or by some complications in the accident, the fragment, if 
displaced at all, always moves downwards toward the hand, or down- 
wards and a little forwards, in the direction of the action of the principal 
muscles which arise from this epiphysis ; and when the fracture or sepa- 
ration is the result of muscular action alone, this form of displacement 
seems to me to be inevitable. In addition to the small size, mobility, 
crepitus, and generally slight displacement of the fragment, which, in 
connection with the age of the patient, are the principal signs of this 
fracture, it may be noticed that there is usually some embarrassment in 
the motions of the elbow-joint, which may be due in part to the swelling, 
and in part to the detachment of the point of bone from and around 
which most of the pronators and flexors of the forearm have their rise. 
In one instance, already quoted, that of the lad aged eleven years, who 
is supposed to have had a detachment of the epiphysis from a direct 
blow, the motions of pronation, with flexion, were not at all impaired, 
neither immediately, nor at any subsequent period, but the fragment 
was never sensibly, or only very slightly, displaced. 

Granger has recorded another class of symptoms, to which I have 
already alluded, his explanation of which, however, I am not prepared 
to admit. One of these cases he describes as follows : A boy, eight 
years old, fell with violence, and broke off completely the whole of the 
inner epicondyle of the right humerus. The lad said he had fallen on 



FRACTURES OF THE INTERNAL EPICONDYLE. 289 

his hand. The fragment was displaced toward the hand. Severe in- 
flammation followed, but he recovered the free and entire use of the 
elbow-joint in less than three months after the accident. No splints or 
bandages were ever employed. 

From the moment of the accident, the little finger, the inner side of 
the ring finger, and the skin on the ulnar side of the hand, lost all sen- 
sation. The abductor minimi digiti and two contiguous muscles of the 
little finger were also paralyzed. This condition lasted eight or ten 
years, after which sensation and motion were gradually restored to 
these parts. As a consequence of this paralyzed condition of the ulnar 
nerve, also, successive crops of vesications, about the size of a split 
horse-bean, commenced to form on the little finger and ulnar edge of 
the hand some weeks after the accident, leaving troublesome excoriations. 
This eruption did not entirely cease for two or three months. 

In two other cases, Mr. Granger remarks that he found " the same 
paralysis of the small muscles of the little finger, the same loss of feeling 
in the integuments, and the same succession of crops of vesicles on the 
affected parts of the hand, as occurred in the preceding case." 

Without intending to intimate a doubt of the accuracy of Mr. Granger's 
statement, that such phenomena have followed in three cases out of the 
five which he has seen, I must express my belief that it was only a re- 
markable concurrence of circumstances, since the same phenomena have 
never been seen by myself, nor do I know that they have been observed 
by any other surgeon ; and that they indicated some injury to the ulnar 
nerve is no doubt correct, but it is not so plain that it was caused by the 
displacement of the fragment. 

Results. — As in all other accidents about the elbow-joint, a temporary 
rigidity is likely to ensue. The mere confinement of the arm in a flexed 
position is sufficient to determine this result without the interposition of 
a fracture ; but when inflammation occurs, more or less contraction of 
the tendons, muscles, etc., about the joint must ensue. To this circum- 
stance, therefore, added to the confinement, rather than to the fracture, 
will be due the anchylosis. If the fragment is not displaced, the frac- 
ture cannot certainly be responsible for the loss of motion, since it does 
not in any w r ay involve the joint ; and if displacement exists, its ulti- 
mate effect in diminishing the power of the muscles which arise from the 
epiphysis must be only trivial and scarcely appreciable. We might, 
therefore, reasonably conclude that where the accident has been prop- 
erly treated, permanent anchylosis would be the exception, and not the 
rule. This view of the matter seems also to be sustained by the recorded 
results. In Granger's cases, the full range of flexion and extension of 
the forearm has been finally restored, or with so trifling an exception as 
not to be observable without close attention, in every instance ; except 
in the one already mentioned, which was originally complicated with dis- 
location ; and even in this case the ultimate maiming was inconsidera- 
ble. Malgaigne, who says " it ought to be understood that in this acci- 
dent articular rigidity is almost inevitable," seems nevertheless to admit 
the justness of Granger's observation as to the final result, if the proper 
means are employed to prevent it. I have myself found only once any 
considerable anchylosis of the joint after the lapse of a few years. 



290 FEACTURES OF THE HUMERUS. 

Treatment. — This accident does not constitute an exception to the rule 
which experience has established, that small epiphyseal projections, when 
once displaced, can seldom be restored completely to, or maintained in 
position. Granger remarks : "I have purposely avoided saying one 
word about replacing the detached condyle" (epicondyle), " and for 
these reasons : during the state of tumefaction of the limb, no means 
could be adopted for confining the retracted condyle in its place, beyond 
that of the relaxation of the muscles ; and both before the tumefaction has 
commenced, and after it has subsided, all endeavors to replace the con- 
dyle, or even to change the position of it, have failed." He even pro- 
ceeds so far as to declare that, while attention ought to be given to the 
reduction of the inflammation by appropriate means, we ought, neverthe- 
less, to instruct the patient to flex and extend the arm daily from the 
moment the accident occurs until the cure is completed, and without any 
regard to the consolidation of the fragment ; " the exercise of the joint 
in this manner must constitute the principal occupation of the patient for 
several weeks ; and should it be remitted during the formation and con- 
solidation of the callus, much of the benefit which may have been derived 
from this practice will be lost, and will with difficulty be regained." 

With only slight qualifications I would adopt the advice of Mr. Gran- 
ger. The limb ought, at first, to be placed in a position of semiflexion, 
so that if anchylosis should unfortunately ensue, it would be in the con- 
dition which would render it most serviceable, and also because in this 
position the muscles which tend to displace the fragment would be most 
completely relaxed. While thus placed, an attempt ought to be made, 
by seizing the epiphysis, to restore it to position ; and if the effort suc- 
ceeds, as it certainly is not very likely to do, a compress and roller 
ought to be so applied as to maintain it in position ; provided, always, 
that it shall not be found necessary to apply the roller so tight as to 
endanger the limb, or increase the inflammation. An angular splint 
would be an almost indispensable part of the apparel, at least with chil- 
dren, where this indication is in view. In no case, however, ought more 
than fourteen clays to elapse before all bandaging and splinting should be 
abandoned, and careful but frequent flexion and extension be substituted. 

In three cases seen by me, a displacement of the fragment, either for- 
wards or backwards, has occurred whenever the arm was flexed, and it 
has been necessary, therefore, to treat the case with the arm in a straight 
position. These are plainly only exceptions to the rule. 

\ 9. Fracture or Diastasis of the External Epicondyle. (Epicondyle, 

Chaussier.) 

The anatomy of the external epicondyle has already been described 
when speaking of the epicondyles generally. Like the internal epicon- 
dyle, it is composed in part of an epiphysis, and in part an apophysis 
projected from the shaft of the humerus, which portions become united 
to each other by bony tissue, usually about the sixteenth or seventeenth 
year of life ; occasionally the consolidation is delayed much longer. 
It is very small, and serves for the attachment of some of the common 
extensors of the forearm and hand, and the external lateral ligament. 



FRACTURES OF THE INTERNAL CONDYLE 



291 



Fig. 83. 



Whether this small epicondyle — speaking now of it as a whole, com- 
posed in part of the epiphysis and in part of the process from the shaft 
of the humerus — whether this can be broken off or separated as a trau- 
matic accident, and as a simple, uncomplicated fracture, needs no longer 
to be discussed. It is plainly impossible, unless the line of fracture in- 
cludes a portion of the joint, and in that case it is to be designated as a 
fracture of the condyle, and not of the epicondyle. 
At least I may say that no satisfactory clinical 
example, or anatomical specimen, has ever been 
presented. 

It is not difficult to admit, however, the possi- 
bility of a detachment of the epiphyseal portion 
prior to its consolidation with the shaft of the hu- 
merus; and, indeed, the occurrence of such an 
accident would seem quite probable, yet we lack 
any absolutely conclusive evidence that it has ever 
taken place. The specimen sent to me by that 
distinguished anatomist Dr. Zuckerkandl of Vienna, 
and to whose communications upon this subject I 
have already referred, when speaking of fracture 
of the epicondyles in general, and of the internal 
epicondyle in particular, will not bear the test of 
a critical examination. It was found in the dissect- 
ing room, and is unaccompanied with any clinical 
history ; but it is evidently from a person near the twentieth year of 
life. There is, indeed, an apparent absence of a portion of the ex- 
ternal epicondyle, and there are two ossicula, situated in the external 
lateral ligament, with smooth, slightly bosselated surfaces. Dr. Z. 
explains the presence of two by supposing it was an exceptional process 
of development; but it is more difficult to explain how the epiphysis 
should have found its way into the lower or distal portion of the external 
lateral ligament, where he correctly states that it is situated. The sup- 
posed original seat is covered in by perfectly formed lamellated tissue, 
and underneath the situation in which the ossicula are found is a deep 
fossa fitted exactly to receive them. 




Supposed fracture of 
the entire external epicon- 
dyle. 



1 10. Fractures of the Internal Condyle. (Trochlea, Chaussier, and 

Malgaigne.) 

According to the nomenclature Avhich I have adopted, those fractures 
alone which involve the joint can be so designated. They are those 
fractures which, commencing outside of the joint above the base of the 
epicondyle, extend downwards and outwards through the articular sur- 
face of the bone ; the condylar fragment carrying with itself more or 
less of the trochlea, in most cases passing through the olecranon fossa, 
the anterior fossa, and the groove of the trochlea. 

Malgaigne regards the occurrence of this fracture as very rare, and 
declares that he has never seen a case. He admits, however, that it 
happens occasionally, and cites a specimen shown to the Socidte Anato- 



292 



FRACTURES OF THE HUMERUS 




Fracture of internal 
condyle. 



Fig. 84. mique by M. Gueneau de Mussy, in 1837, which 

had united with the fragments in place. 

On the other hand, Sir Astley Cooper, B. 
Cooper, South, Gurlt, and others, speak of it as a 
frequent fracture, especially in children. For my- 
self I have a record of twenty examples of this 
fracture seen by myself, while the number of frac- 
tures of the external condyle recorded by me is 
twenty-nine ; this difference in frequency being 
slight, but a little in favor of the external condyle. 
Causes. — It has already been stated that frac- 
tures of the internal condyle, as well as fractures 
of the epicondyle, belong almost exclusively to 
infancy and childhood, only two instances having 
come under my notice after the eighteenth year of 
life. 

I have seen no instance which could be traced 
to any other cause than a direct blow, such as a fall upon the elbow, the 
force of the concussion being received directly upon the condyle. 

Line of Fracture, Displacement, Symptoms. — The direction of the 
line of fracture is tolerably uniform, namely, commencing about one- 
quarter or half an inch above the epicondyle, it extends obliquely out- 
wards through the olecranon and coronoid fossae, and enters the joint 
through the centre of the trochlea. 

Displacement of the lower fragment can take place only in a direction 
upwards, backwards, forwards, and inwards (to the ulnar side). The 
fragment cannot be carried downwards, in the direction of the hand, nor 
outwards, in the direction of the radius, unless the radius also is broken 
or dislocated. 

The most common form of displacement is upwards and backwards, 
and perhaps at the same time a little inwards ; the ulna remaining at- 
tached to the low T er fragment, and following its movements. I have 
seen one instance in which the fragment was carried directly downwards 
toward the hand, but this action was originally complicated with a dislo- 
cation of the radius backwards. The dislocation was immediately 
reduced. Five years after, when the young man was twenty-three years 
old, I found the condyle displaced downwards and forwards about half 
an inch, so that when the forearm was extended it became strikingly 
deflected to the radial side. 

The symptoms which characterize this fracture are crepitus, almost 
always easily detected ; mobility of the fragment, discovered especially 
by seizing upon the epicondyle, or by flexing and extending the arm ; 
displacement of the smaller fragment and a projection of the olecranon 
process, this latter being very marked when the forearm is extended 
upon the arm, but almost completely disappearing when the elbow is 
bent ; projection of the lower end of the humerus in front when the arm 
is extended ; the humerus shortened when measured along its ulnar side, 
from the internal epicondyle ; the breadth of the humerus through its 
condyles generally increased slightly, sometimes half an inch or more ; 



FRACTURES OF THE INTERNAL CONDYLE. 293 

if the lesser fragment is carried upwards, it will also be found that when 
the limb is extended, the forearm will be deflected to the ulnar side. 

Sir Astley Cooper remarks that it is frequently mistaken for a dislo- 
cation ; and Thomas M. Markoe, of New York, has shown that it is, in 
fact, frequently complicated with a dislocation of the head of the radius 
backwards ; indeed, he expresses a belief that this dislocation of the 
radius seldom or never occurs without a fracture of the internal conckyle. 1 

Results. — It is probable that in a majority of cases no permanent 
displacement exists ; although the irregularity of the bony deposits 
around the base of the connyle, which generally may be easily felt, 
would lead to a contrary opinion. The fact that the lower fragment 
usually follows the motions of the olecranon, renders its replacement 
and retention comparatively easy, unless some complication exists. It 
is not from displacement, therefore, so much as from permanent muscu- 
lar, and especially bony anchylosis, that serious maiming so often results. 
Under any treatment bony anchylosis will very often ensue, and under 
improper treatment it is almost inevitable. 

Treatment. — The arm must be immediately flexed to nearly or quite 
a right angle, when, without much manipulation, the fragments will be 
made to resume their place. A gutta percha, or felt, right-angled 
splint, such as I have already directed for fractures occurring just above 
the condyles, well and carefully cushioned, may now be applied, and 
secured by rollers. Suitable pads must also aid the splint and roller, 
in keeping the fragments in place. Markoe prefers keeping the forearm 
in a position about ten degrees short of a right angle, believing that in 
this position the ulna itself will act as a splint, and, by its support on 
the uninjured portion of the trochlea, hold in its place the broken con- 
dyle. Very properly, also, he prefers to lay the angular splint, made 
of tin, and fitted to the arm and forearm, upon the back of the limb, in- 
stead of upon the front or sides. If it is upon the inside, it covers the 
broken condyle, and we are unable to know so well its position ; if upon 
either side, it is apt to press injuriously upon the epicondyles ; and if it 
is in front, the fragments cannot be so well adjusted or supported. Upon 
this point, however, surgeons are not very well agreed, and no doubt 
more will depend upon the care with which the splint is applied than 
upon the surface against which it is laid. 

Considerable swelling is almost certain to folio w, and no surgeon 
ought to hazard the chances of vesications, ulcerations, etc., by neglect- 
ing to open or completely remove the dressings every day. Within 
seven days, and perhaps earlier, passive motion must be commenced, 
and perseveringly employed from day to day until the cure is accom- 
plished ; indeed, in a majority of cases it is better not to resume the use 
of splints after this period ; for, although at this time no bony union has 
taken place, yet the effusions have somewhat steadied the fragments, and 
the danger of displacement is lessened, while the prevention of anchylo- 
sis demands very early and continued motion. 

When the fracture is compound, or otherwise complicated, these simple 

1 Markoe, New York Journal of Medicine. May, 1855, p. 382, second series, vol. xiv. 
Also paper read before N. Y. Surg. Soc, Mar, 1880. 



294 FRACTURES OF THE HUMERUS. 

rules will seldom be found applicable ; indeed, fractures attended with 
no such complications will occasionally be found difficult to reduce, or" 
to maintain in position after reduction. 

§ 11. Fractures of the External Condyle. 

It is necessary again to call attention to the fact that the author re- 
cognizes no fractures as fractures of the condyles, either external or in- 
ternal, which do not enter the joint. All not included in this definition 
and occurring in these regions, are epicondylar fractures or diastases. 

Causes. — All the fractures (29) of the external condyle, of which I 
have a record, occurred in children under fifteen years of age, except 
two ; one, in which a woman, eighty-eight years of age, fell upon her 
elbow when intoxicated, breaking off* the outer condyle. Two months 
after the accident I found the fragment displaced half an inch upwards, 
and firmly united. The other was a man get. 49. 

In a large majority of these cases the patients themselves have af- 
firmed, and the surface of the skin has furnished conclusive evidence, 
that the fracture was produced by a direct blow, generally by a fall upon 
the elbow. 

Line of Fracture, Displacement, and Symptoms. — The direction of 
the fracture is generally such that, commencing always above and with- 
out the capsule, it descends obliquely and enters the joint either just 
within or through the " small head" or articulating surface upon which 
the radius is received ; or else it penetrates more deeply in its progress, 
and passing through the olecranon fossa, it enters the joint through the 
middle of the trochlea. 

In the first of these classes of examples, which I think also is the most 
common, the condyle alone is broken off, and it is liable only to become 
displaced backwards, forwards, or outwards ; generally, I have found it 
displaced a little outwards, sufficiently to increase manifestly the breadth 
of the condyles, or it has been carried backwards ; once slightly forwards ; 
it is also, in some cases, carried upwards in a small degree, although 
the action of the supinators and extensors would seem to render a down- 
ward displacement more common. These displacements are usually not 
considerable, and in a few cases there is none at all. Whatever may 
be the direction or degree in which the fragment is moved, however, the 
head of the radius is found almost always to accompany it ; but in the 
case which I am about to relate, the head of the radius became com- 
pletely separated from the condyle. 

Frederick KeafFer, set. 11, fell from a load of hay, and he is confident 
that he struck the ground with the back of his elbow. Six hours after 
the accident he was brought to me by the physician who was first called 
to him. The arm was much swollen, and the external condyle could 
not be distinctly felt, but when pressure was made directly upon it, crep- 
itus and motion became manifest. The head of the radius was at the 
same time dislocated backwards, and separated entirely from the con- 
dyle, its smooth button-like head being very prominent. It is difficult 
to conceive how a blow from behind should leave the head of the radius 
dislocated backwards, or how the radius could have separated from the 







FRACTURES OF THE EXTERNAL CONDYLE. 295 

broken condyle ; but as the examination was repeated several times, and 
while the patient was under the influence of ether, I have no doubt of 
the fact. Several other surgeons who were present concurred with me 
m opinion fully. 

While prosecuting the examination, I reduced the dislocation of the 
radius, but it would not remain in place a moment when pressure or sup- 
port was removed. The lad recovered with a very useful arm, the mo- 
tions of flexion and extension, with pronation and supination, after the 
lapse of a year, being nearly as complete as before 
the accident, the radius remaining unreduced. FlG - 85 - 

Sometimes it will be noticed that while the por- 
tion of the condyle which is attached to the radius 
falls backwards, its upper and broken extremity 
pitches forwards ; and this attitude it is especially 
prone to assume when the forearm is extended. 

It is even possible, when the fracture traverses 
the trochlea, for the ulna also to become displaced 
backwards along with the radius and the lesser frag- 
ment. 

Crepitus, which is usually very distinct, is most 
easily obtained by rotating the radius, or by seizing 
upon the condyle with the thumb and fingers, and 
moving it backwards and forwards. 

-r, ° 7 , ^ ,. ., 1 1 • r» i -i Supposed fracture of the 

Results. — Ordinarily, this fragment unites external condyle. 

promptly, and by the interposition of a bony callus ; 
but in five cases, I have noticed that either no union has occurred, or 
the union has been accomplished only through the medium of fibrous 
structures, and the fragment continued afterward to move with the radius. 

As a consequence, probably, of the displacement of the lesser frag- 
ment upwards, the forearm, when straightened, is occasionally found de- 
flected to the radial side. The surgeon must not, however, confound the 
deflection which is natural, and which is greater in children than in 
adults, with the unnatural radial inclination which is occasioned some- 
times by this accident. I have met with this phenomenon three times in 
children under three years of age, in one of which I could not discover 
that the condyle was carried toward the shoulder, but only outwards : in 
each of the other cases the fragment had united by ligament. The fol- 
lowing is one of the examples referred to : — 

A girl, get. 3, fell and broke the external condyle of the left humerus, 
the fracture extending freely into the joint ; crepitus distinct ; forearm 
slightly flexed ; prone. Lesser fragment displaced outwards and a 
little backwards, carrying with it the radius. On the second day I was 
dismissed on account of the unfavorable prognosis which I gave, or rather 
because I refused to guarantee a perfect limb, and an empiric was em- 
ployed. 

July 2, 1857, several months after the accident, the father brought 
her to me for examination. There was no anchylosis, but the lesser 
fragment had never united, unless by ligament, moving freely with the 
head of the radius. When the forearm was straightened upon the arm, 



296 FRACTURES OF THE HUMERUS. 

it fell strongly to the radial side, but resumed its natural relation again 
when the elbow was flexed. 

Two other examples are reported at length, in the second part of my 
Report on Deformities after Fractures, as Cases 57 and 59 of fractures 
of the humerus. 

In one other example, however, mentioned also in my report as Case 
66, the deflexion was to the opposite side. I examined the lad one year 
after the accident, he being then five years old, and I found the external 
condyle very prominent and firmly united, but not apparently displaced 
in any direction except outwards. The radius and ulna had evidently 
suffered a diastasis at their upper ends, but all of the motions of the joint 
were free and perfect. 

Dorse v 1 speaks of this lateral inclination as being always to the ulnar 
side, but does not indicate to what particular fracture of the elbow it 
belongs. He has also described a splint, contrived by Dr. Physick, 
intended to remedy the deformity in question. 

Chelius also speaks of the same deformity as occurring after fractures 
of the internal, but does not mention it in connection with fractures of 
the external condyle, that is, an inclination of the forearm to the ulnar 
side. 

In more than half of the cases of fracture of this condyle some degree 
of anchylosis has resulted, lasting at least several months. I have seen 
it remaining after a lapse of from one to twenty years, but generally it 
gradually diminishes, and, in a majority of cases, completely disappears 
after a few years. 

Treatment. — I do not know that I need add much to what has already 
been said in relation to the treatment of fractures of the opposite con- 
dyle, and at the base of the condyles, since the measures applicable to 
the one are, in general, applicable to the other. 

Generally, the forearm ought to be flexed upon the arm, especially 
with a view to overcome the usual tendency in the upper end of the lower 
fragment to pitch forwards, and which form of displacement is greatly 
increased by straightening the arm. A remarkable exception to this 
rule, and one of two which I have seen, must be mentioned. 

James Cronyn, aged 6, was brought to me in March, 1857, having, 
a few minutes before, fallen from a height of four or five feet to the 
ground. His father said the elbow had been broken at the same point 
two years before, and from that time had remained stiff and crooked. I 
found the external condyle broken off, and, with the head of the radius, 
carried backwards. This was the position which it occupied constantly, 
though it was easily restored and maintained in position when the arm 
Avas straight, but not by any possible means when the elbow was flexed. 
I dressed the arm, therefore, in an extended position, with a long felt 
splint, and the fragments remained well in place until a cure was accom- 
plished. 

It is especially deserving of notice that, in the five cases in which I 
have observed bony union to fail, and the fragments to continue mova- 
ble, the motions of the elbow-joint have, in a very short time, been com- 

' Elements of Surgery, by Philip Syng Dorsey, Phila. ed., 1813, vol. i. p. 146. 



FRACTURES OF THE EXTERNAL CONDYLE. 297 

pletely restored. If it does not prove that Granger was correct in his 
views as applied to fractures of the internal epicondyle, namely, that it 
was of little or no consequence whether the fragment united or not, and 
that the elbow-joint ought to be submitted to free motion from the begin- 
ning to the end of the treatment — if it does not absolutely prove, I say, 
the correctness of his views, it at least must abate our apprehensions of 
the supposed evil results of non-union in the case of the fracture now 
under consideration. 

I shall take the liberty of quoting also, with a qualified approval, the 
opinion of Dr. John C. Warren, of Boston, as stated by Dr. Norris in his 
Report on Surgery, made to the American Medical Association in 1848. 

" In the treatment of fractures of the condyles of the os humeri, a 
course is usually recommended which he believes to be hurtful, inas- 
much as it favors the worst consequences of the injury, namely, loss of 
motion in the joint. By this mode of treatment, the fractured piece 
becomes sufficiently fixed to create partial anchylosis ; and there is so 
much pain afterwards in the proposed passive movements as to cause the 
omission of these measures until permanent stiffness takes place. The 
proper course in the management of these accidents, he conceives to be 
— 1st. To apply no splints, but in the earlier clays to make use of the 
proper means to prevent inflammation. 2d. To accustom the patient to 
early and daily movements of flexion and extension. 3d. When the 
action of the joint becomes limited, to overcome the resistance by force, 
and repeat it daily until the tendency of the joint to stiffen ceases. 

" The accomplishment of this process, he adds, is so very painful that 
few patients have courage to submit to it, and few surgeons firmness to 
prosecute it. The consequence has been that in a great number of cases 
the use of the articulation to a greater or less extent has been lost. The 
introduction of etherization, by preventing the pain, gives us, in the 
opinion of Dr. Warren, the means of overcoming the resistance. By its 
aid he has restored the motion of a considerable number of anchylosed 
elbows, and has successfully applied the same measures to other joints, 
particularly to the shoulder and knee. This has now become his settled 
practice, with the results of which he is entirely satisfied. The inflam- 
mation consequent upon the forced movements of an anchylosed joint is 
not to be losed sight of. By a reasonable abstraction of blood, and other 
anti-inflammatory treatment, he has never found it alarming." 1 

My respect for the distinguished surgeon whose opinion is here given 
does not permit me to question the correctness of his practice ; but I 
cannot avoid a belief that his language does not convey a precise idea 
of his views. If he intends to say that he would move the joint freely 
when it is suffering from acute inflammation, and when motion occasions 
great pain, I must protest against the practice as likely to do vastly 
more harm than good in any case; but if he would move the joint from 
the first, when the inflammation and swelling are trivial, and when it 
occasions only an endurable amount of pain, then his views are just and 
his practice worthy of imitation. 

1 Transactions of the American Medical Association, vol. i. p. 174. 
20 



298 FRACTURES OF THE RADIUS. 



CHAPTER XXIT. 

FRACTURES OF THE RADIUS. 

Of one hundred and twenty-seven fractures of the radius which have 
been recorded by me, not including gunshot fractures, or fractures de- 
manding immediate amputation, three belonged to the upper third, ten 
to the middle third, and one hundred and fourteen to the lower third. 
Of those belonging to the lower third seven were through the shaft, 
more than two inches above the lower end, two were fractures of the 
styloid processes, and the remainder, one hundred and five, were Colles's 
fractures. Five were compound, and one hundred and twenty-two sim- 
ple. Sixty- nine are reported as occurring in males, and fifty-eight in 
females ; sixty-one as having occurred in the left arm, and forty-one in 
the right. 

Fracture of the neck of the radius, as a simple accident, uncompli- 
cated with any other fracture or dislocation, is exceedingly rare ; yet, 
owing to the depth of the superincumbent mass of muscles, and the 
difficulty of determining, where so many bones and processes approach 
each other, precisely from what point the crepitus, if any is found, 
proceeds, surgeons have often been deceived, and they have believed 
that they were the fortunate possessors of this rare pathological treas- 
ure, when the autopsy has too soon disclosed their error. Both B. 
Cooper and Robert Smith have alluded to this difficulty, and the case 
reported by Dr. Markoe to the New York Pathological Society, and 
published in the American Medical Monthly, will serve to illustrate the 
same point ; in which case the signs of a fracture of the radius at its 
neck were such as to deceive that experienced surgeon, yet the autopsy 
disclosed the fact that it was a dislocation of the head of the radius 
forwards, with a fracture of the ulna. Indeed, its existence as a form 
of fracture was doubted by Sir Astley Cooper, and by others has been 
actually denied. I have seen no specimen obtained from the cadaver, 
except the doubtful one contained in Dr. Watts's cabinet, and of which I 
have furnished an account, accompanied with a drawing, in my report to 
the American Medical Association, 1 and the specimen owned by the late 
Dr. Mutter, of Philadelphia, of which he has kindly furnished me the 
following description : " History unknown. The line of fracture seems 
to have passed through the neck of the left radius, just at the upper 
extremity of the bicipital protuberance. Union with deformity has 
resulted. Owing to the fracture having taken place within the inser- 
tion of the biceps, that muscle appears to have drawn forward and 
upward the lower end of the short upper fragment. In consequence of 

1 Transactions, vol. ix. pp. 157 and 229. 



FRACTURES OF THE ]STECK OF THE RADIUS 



299 



Fig. 86. 



this movement, the articulating facet of the head of the radius is tilted 
backwards, so as no longer to be in contact with the humerus. As a 
secondary consequence, the anterior edge of the head of the radius rests 
permanently against the articulating surface of the humerus. At this 
new point of contact a new surface of articulation is seen to have been 
formed, while the original articulating facet is 
directed backwards, and lies at right angles to 
the one of more recent formation. At the 
inner edge of the new articulation of the head 
of the radius with the humerus, contact with 
the ulna has developed another surface of ar- 
ticulation. The upper and lower fragments 
are united at an angle, and the radius does 
not appear to have lost in length." 

Velpeau has once demonstrated the exist- 
ence of this fracture in a dissection, but the 
fracture was accompanied with a fracture 
also of the coronoid process ; and Be'rard 
obtained possession of a similar specimen. 
I do not remember to have seen a notice of 
any others. Malgaigne affirms, with his usual 
frankness, that although he has occasionally 
believed that he had met with it, the autopsy, 
whenever it has been obtained, has shown 
that it was rather a subluxation than a frac- 
ture. On the other hand, Mr. South calls it 
a " not unfrequent accident," but in confirma- 
tion of this declaration he cites no examples. 

While, therefore, the presence of what ap- 
pear to be the rational diagnostic signs has 
compelled me to record one case as an uncom- 
plicated fracture of the neck of the radius, 
and two others as fractures at this point accom- 
panied either with a fracture of the humerus 
or a dislocation of the ulna, I am prepared to admit that some doubt 
remains in my own mind as to whether in either case the fact was 
clearly ascertained ; nor do I think, speaking only of the simple frac- 
ture, that it will ever be safe to declare positively that we have before 
us this accident, lest, as has happened many times before, in the final 
appeal to that court whose judgment waits until after death, our decisions 
should be reversed. 

Nothing, perhaps, could more fully illustrate the difficulty of diag- 
nosis in the case of injuries received in the neighborhood of the head 
of the radius than the testimony given in the case of Noyes vs. Allen, 
tried in the Supreme Court at Cambridge, January, 1856, before Judge 
Bigelow. Mr. Noyes injured his elbow, January 7, 1854, and Dr. 
Allen, who was called immediately, believed that the ligaments of the 
joint had been torn, but that no bones were broken or displaced. On 
the following morning he was dismissed, and Mr. Noyes went home. 
Three weeks later it was seen by Dr. Dow, who also thought there was 




Fracture of neck of radius (Mut- 
ter's cabinet), a. Original articu- 
lating facet, b. New articulating 
facet, c. Projecting fragments. 



300 FRACTUKES OF THE RADIUS. 

no fracture. About eight weeks after the accident a physician examined 
the arm, and declared the neck of the radius broken, and the fragments 
displaced ; and when the case was finally brought to trial he testified 
still that such was certainly the fact ; and five other physicians, not one 
of whom, however, we are told, was a member of the State Medical 
Society, testified positively that the radius was broken at its neck, pro- 
ducing a bony protuberance ; that such an injury only could account for 
the symptoms manifested at the time of the accident, and that no other 
fractures or injuries of the joint could explain so well the present 
appearances of the arm. While, on the part of the defence, six of the 
most intelligent medical gentlemen of the State, Drs. Kimbal and Hun- 
tington, of Lowell, and Drs. Townsend, Lewis, Clark, and Gay, of 
Boston, testified that the head and neck of the radius were not dis- 
placed, nor was there any evidence that this bone had ever been broken. 
There is every reason to believe that these latter gentlemen were cor- 
rect ; yet it is to be presumed that the gentlemen who first testified were 
not without some grounds for their opinions so confidently expressed. 

The case was given to the jury after a trial of five days, who promptly 
returned a verdict for the defendant. 1 

When the fracture occurs, the upper end of the lower fragment will 
probably be carried forwards by the action of that portion of the biceps 
which has its insertion into the tubercle ; and the displacement in this 
direction must necessarily be increased in proportion as the arm is 
straightened. In the cabinet specimens belonging to Dr. Mutter, the 
line of fracture, commencing in the neck, has terminated in the tubercle ; 
consequently the biceps, having still some attachment to the upper frag- 
ment as well as the lower, has drawn them both forwards. 

The same anterior displacement I have noticed in all of the supposed 
living examples, but whether both fragments or only one had suffered 
displacement I am unable to say. 

A girl, set. 11, living in Ontario Co., N. Y., fell from a tree, and in- 
jured her right arm. Her surgeon, who regarded it as a fracture of 
the neck of the radius, reduced the fragments, and placed the forearm 
at a right angle with the arm. On the twenty-eighth day all dressings 
were removed, and the patient was dismissed; the fragments seemed to 
be in place. The parents, finding the elbow stiff, now made violent and 
successful efforts to straighten the arm. 

Fifteen months after the accident, the child was brought to me. 
There was at this time a bony projection in front, opposite the neck of 
the radius, which I believed to be the point of fracture. The hand was 
forcibly pronated, and she had only a limited amount of motion at the 
elbow-joint. The anchylosis was probably due to inflammation directly 
resulting from the severe contusion; but it is quite probable that the 
forward displacement of the fragments was alone due to the too early 
and too violent attempts to straighten the arm ; at least, this was the 
explanation which I ventured to give to the parents at the time. 

The second case occurred in a lad eight years old, living in Wyoming 
Co., N. Y. His parents brought him to me ten weeks after the injury 

1 Amer. Med. Gazette, vol. vii. p. 299. 



FRACTURES OF THE NECK OF THE RADIUS 



301 



Fig. 87. 



/ 



was received, and I then found the forearm bent to a right angle with the 
arm, and anchylosed at the elbow-joint. The hand was also forcibly pro- 
nated, and could not be supinated. In front, and 
opposite the neck of the radius, there was a dis- 
tinct bony projection, which I believed to be the 
point of union of the bony fragments. The exter- 
nal condyle seemed also to have been broken. 

The third example, treated originally by Dr. 
Nott, of Buffalo, was seen by me six months after 
the accident. The upper end of the lower frag- 
ment seemed to be displaced forwards. There 
was very little motion at the elbow-joint, and 
both pronation and supination were completely 
lost. 

I have seen, in Dr. Mutter's cabinet, two speci- 
mens of fracture of the outer half of the head of 
the radius. In one case, the small fragment is 
slightly displaced downwards in the direction of 
the axis of the bone ; and, in the other, the frag- 
ment is thrown outwards, or to the radial side. 
Both are firmly united in their new positions. 

Dr. Hodges presented to the " Boston Society 
for Medical Improvement" a specimen very much 
resembling those of Dr. Mutter's, in which case 
the patient survived his injuries only six hours; 
and in the examination after death he was found 
to have also an oblique fracture of the shaft of 
the ulna, the line of fracture commencing above 
the coronoid process-, and extending obliquely 
downwards and backwards. He remarks, more- 
over, that he has three times found a longitudinal 
fracture at the head of the radius associated with 
a fracture of the coronoid process of the ulna. 1 
I have already observed that Velpeau had once 
noticed the same coincidence. 

In the treatment of fractures of the neck of the 
radius, we must not neglect to flex the forearm 
upon the arm, so as to relax, as completely as pos- 
sible, the biceps, whose advantageous insertion 
into the tubercle of the radius would be certain to produce displacement, 
unless this position was adopted. A single dorsal splint, properly 
padded, should support the forearm, while the surgeon, having placed a 
compress over the upper end of the lower fragment, proceeds to secure 
the whole with a roller. 

Especial care must also be taken to prevent the forearm from being 
extended before the bony union is fairly consummated, lest the biceps, 
now firmly contracted, should draw the lower fragment forwards, as it 
must inevitably do while the bony union is imperfect; an accident 



I 



Fracture of head of : 
(Mutter's Collection, 
men A, No. 105.) 



adius. 
Speci- 



1 Hodges, Boston Med. and Surg. Journ., Dec. 6, 1866. 



302 FRACTURES OF THE RADIUS. 

which, there is some reason to believe, occurred in one of the examples 
which I have already cited. 

If the patient be a child, or if there is any reason to suppose that 
these rules will hot be faithfully complied with, it would be well to 
secure the arm in this position with a right-angled splint. 

When the fracture occurs in any portion of the radius below the in- 
sertion of the biceps, and above the insertion of the pronator radii teres, 
Mr. Lonsdale suggests the propriety of placing the forearm in a condition 
of supination, at least so far as practicable, for the purpose of securing 
a proper apposition of the fragments. His argument in favor of this 
practice is ingenious, and deserves consideration. 

When the bone is broken anywhere in this portion, the action of the 
pronators upon the upper fragment ceases ; while that of the biceps, 
which is a powerful supinator, continues ; consequently the upper frag- 
ment becomes at once, and completely, rotated outwards or supinated. 
Now, if the hand, to which the lower end of the radius alone remains 
attached, should be forcibly pronated, the radius will also be rotated 
inwards upon its own axis; and although it might be possible in this 
condition to bring the broken ends into contact, and a bony union, with- 
out deformity, might be consummated, yet the power of supination must 
be forever lost ; since the union has been effected while the head and 
upper fragment are already in a state of complete supination ; and if 
such is the fact, it is evident that the whole bone, together with the 
hand, will be incapable of any further supination. 

It is not, indeed, the practice with any surgeons, so far as I know, to 
treat this fracture with the hand placed in a position of extreme prona- 
tion ; but the case has been supposed for the purpose of rendering the 
argument more intelligible. The usual practice is to place the forearm 
and hand in a position midway between supination and pronation, and 
then to lay it across the body at a right angle with the arm ; but it is 
plain that the same objection, differing only in degree, will apply to this 
position as to that of pronation. The axes of the two fragments are not 
made to correspond, since, while the lower fragment is only half rotated 
outwards, the upper fragment is completely, and the result of the union 
must be the loss of one-half the power of supination in the hand. 

It is only, then, by complete supination of the hand during treatment 
that this difficulty can be avoided, and I have no doubt that we ought to 
adopt this plan, whenever it is practicable to do so, or whenever we are 
not hindered by serious obstacles ; and the only obstacle which occurs 
to me as likely to interpose itself, is the practical one which most sur- 
geons must have experienced in treating all injuries of the forearm, 
whether fractures, or only severe contusions of the muscles, etc., namely, 
the constant and almost uncontrollable tendency of the hand to assume 
the prone or semi-prone position. This is due, no doubt, to the great 
preponderance of power in the pronators ; and such is the resistance 
which they afford to supination that it is often quite impossible to lay 
the hand upon its back while the forearm is across the body, and, if 
accomplished, the position generally becomes in a few hours so painful 
as to be intolerable. By extending the arm, however, and laying it 
upon a pillow, the hand will be found again to rest easily upon its back, 



FRACTURES OF THE HEAD OF THE RADIUS, 



303 



because in this way we avail ourselves of the outward rotation of the 
humerus at the shoulder-joint. 

Dr. X. C. Scott, formerly Resident Surgeon to the Brooklyn City 
Hospital, in his inaugural thesis, submitted in March, 1869, has dis- 
cussed very fully the advantages of this position in many fractures of 
the forearm, and he has devised a very ingenious mode of securing the 
limb after supination is effected, adding also a moderate amount of ex- 
tension by adhesive plasters and elastic bands. 



Fig, 




Scott's apparatus for fractures of the forearm. 

Dr. Scott informs me that he has treated twenty-five cases very suc- 
cessfully at the Brooklyn City Hospital and elsewhere, by this method. 

It has already been stated that of the whole number of fractures of 
this bone recorded by me, amounting in all to 127, only 10 belonged to 
the middle third; an observation which is in striking contrast with the 
remark of Chelius, that it is broken most frequently in its middle. 

If the fragments are completely separated in the middle third, the 
lower end of the upper half is drawn forwards by the action of the 
biceps aided by the pronator radii teres, in case the fracture is below its 
insertion ; while the lower fragment is tilted toward the ulna by the con- 
joined action of the supinator radii longus and pronator quaclratus. But 
as to the direction of the displacement much will depend upon the direc- 
tion of the force by which the fracture has been occasioned. 

A laboring man, set. 35, broke the radius near the lower end of the 
middle third. On the same day I replaced the fragments as well as I 
could in the midst of the swelling which had already occurred, and 
applied two broad and well-padded splints, one to the palmar and one 
to the dorsal surface of the forearm. 

On the twenty-eighth day I first discovered that the fragments were 
projecting in front, and I at once proposed to thurst them back by 
force, but the patient declined allowing me to do so. I then applied a 
compress near the summit of the projection, but not exactly upon it, 
lest it should cause ulceration, and secured over this a firm splint. At 
first this seemed to produce a change in the fragments, but after a 



304 FRACTURES OF THE RADIUS. 

couple of weeks I found there was no improvement, and it was discon- 
tinued. About six months after the fracture occurred, this man had 
the same arm terribly lacerated in a railroad accident, and I was 
obliged to amputate near the shoulder-joint ; and I thus obtained the 

Fig. 89. 




Fracture of the shaft of the radius. (From Gray.) 

broken radius. The bone was firmly united, but with an angle, salient 
forwards, of about ten degrees. There was no inclination toward the 
ulna. 

My impression is that these fragments were never completely re- 
placed, a point which I could not well determine at first on account of 
the rapid effusion. If they had been, I think they could have been 
retained in place with the appliances used. Almost every day the limb 
was examined, and as often as every fourth or fifth day the dressings 
were removed and carefully reapplied. And only once did they become 
so loose as not to afford the requisite support, and this at a period too 
late to have occasioned the deformity. 

We ought not to be deceived, therefore, and promise too confidently 
a perfect limb, even when but the radius is broken, since we may not 
always be certain that the ends are well replaced, or perhaps they may 
become displaced subsequently, and in either case we are not likely to 
discover the deformity until the swelling has subsided, and it is too late 
to apply the remedy. 

In the treatment of fractures of the middle third, the same rules, 
with only slight modifications, will be applicable, as in fractures of 
both bones. Two straight, long, and broad splints must be applied 
after being carefully padded ; and especial attention should be paid to 
the tendency of the fragments to become displaced forwards and toward 
the ulna through the action of both the biceps and the pronator radii 
teres ; a tendency which may in some measure be provided against by 
flexion of the arm, but which must be overcome chiefly by steady and 
well-adjusted pressure, near, but not upon, the ends of the fragments. 

Fractures of the lower third, occurring above the line of Colles's 
fracture, are almost as rare as fractures of the middle or upper thirds. 
I have recorded seven ; one of which it will be proper to relate as a 
representative example. 

George Vogel, set. 30, was admitted to the Buffalo Hospital of the 
Sisters of Charity, Nov. 2, 1852, with a fracture of the right radius 
about three and a half inches above its lower end. The hand was 
prone, and inclined to the radial side ; while the broken ends of the 



COLLES'S FRACTURE. 305 

radius fell against the ulna, from which it was found difficult to separate 
them. The lower end of the ulna was prominent, and projecting upon 
the ulnar margin of the hand. 

I was unable completely to separate the fragments of the radius from 
the ulna, by either pressure with my fingers between the bones, or by 
seizing upon them with my thumb and fingers. Having, however, 
adjusted them as well as possible, I flexed the arm, and applied a broad 
and well-padded, splint to the palmar surface of the forearm, securing 
it in place with a paste bandage. These dressings were finally removed 
at the end of four weeks, when I found scarcely any displacement or 
deformity remaining. 

Most of these fractures of the shaft in its lower end, when properly 
treated, result in perfect limbs. In a certain proportion, however, it 
will be found impossible effectually to resist the action of the pronator 
radii teres and of the quadratus, and the fragments will unite at an angle 
resting against the ulna, and sometimes, by the interposition of inter- 
mediate callus, they will become firmly united to the ulna. Occasion- 
ally, also, especially where the fracture has been produced by a fall 
upon the hand, and the radio-ulnar ligaments of the wrist have been 
torn or stretched, the lower end of the ulna will be found to project 
permanently, and the hand to fall more or less to the radial side. In 
examples of this kind, of which I have seen one or two, the cause and, 
to some degree, the manner of the displacement are such as to entitle 
them perhaps to be regarded as true Colles's fractures ; but we have 
found it convenient to restrict the use of this title to fractures occurring 
within at least one inch and a half of the joint. 

Colles's Fracture. — Of the one hundred and fourteen fractures belong- 
ing to the lower third of the radius, one hundred and five w T ere near the 
lower end, or within from half an inch to one inch and a half from the 
articular surface, all except two styloid fractures being included in those 
fractures called " Colles's fractures," most of which were no doubt true 
fractures, and probably a small proportion separations of the epiphyses. 

In every instance, except one, which has come under my notice, 
where the cause of a Colles's fracture has been ascertained, it has been 
occasioned by a fall upon the palm of the hand. The exceptional case 
was in the person of Mrs. D. B., who fell in getting out of a street car 
in the city of New York, May 20, 1865, striking upon the back of her 
hand while the hand was shut. The displacement was in the same 
direction as in cases caused by a fall upon the palm. Robert Smith 
has seen a similar accident cause a displacement of the fragment for- 
wards. 

Colles described this fracture as occurring always about one inch and 
a half above the carpal end of the bone ; l but Robert Smith, who has 
carefully examined all of the cabinet specimens he could find, about 
twenty-three in number, has never seen the line of fracture removed 
farther than one inch from the lower end of the bone, and in several 
specimens it was within one-quarter of an inch of this extremity. Du- 
puytren has also described the fracture as occurring from three to 

1 Colles, Ed. Med. and Surg. Journ., vol. x. p. 1S2, 1814. 



306 



FKACTUEES OF THE RADIUS 



twelve lines above the joint. I shall refer to this subject again in con- 
nection with experiments upon the cadaver instituted by Pilcher and 
others, merely adding in this place that my own experience and my 
examination of cabinet specimens, together with experiments upon the 
cadaver, convince me that Dupuytren is essentially correct in his state- 
ment above quoted. 

Fig. 90. * 




Fracture of the radius near its lower end. (Colles's fracture.) 

Case. — George Lofinch, get. 42, fell upon an icy sidewalk, striking 
upon the palm of his left hand. Fracture three-quarters of an inch 
above the lower end. Fragment displaced backwards. A friend had 
partially replaced the fragment by pushing upon it, before he came to 
me. Within half an hour after the accident he was at my office, and I 
restored the lower end of the bone very easily to place by pushing from 
behind with my thumb. No extension was necessary. It would not, 
however, remain in place unless the forearm was pronated so that the 
weight of the hand could aid in the retention. 

I applied my own palmar splint. The recovery was rapid and com- 
plete. 

Case.— Margaret Reed, set. 48, fell, September 23, 1855, striking on 
the palm of the left hand, and breaking the radius about one inch from 
its lower end. One week after, she came under my care at the hospital. 
The arm had been previously dressed carefully by one of my colleagues, 
with curved dorsal and palmar splints ; but, on examination, we found 
the fragments a good deal displaced. It was found necessary now to 
use both extension and pressure from behind to restore the lower frag- 
ment to position. This we finally succeeded in doing, and immediately 
splints were again snugly applied. Two days after, on opening the 
dressings, the lower fragment was a second time found displaced back- 
wards. It was again reduced, but only by using great force. Fifteen 
days later, we were pleased to find the bone firm and without deformity. 

Margaret left the hospital on the 4th of November, with her hand and 
wrist still swollen, and with a good deal of stiffness at the elbow and 
wrist-joints. 

Case.- — Charles Stratton, a healthy and temperate laborer, set. 36, fell 
forwards from a wagon, November 22, 1854, striking upon the palm of 
his hand, and breaking the radius at a point apparently a little more than 
one inch above the joint. I found the lower fragment displaced back- 
wards, and it was easily reduced by pressure in the opposite direction. 
The forepart of the wrist being quite tender to pressure, the splint was 
applied to the dorsal surface of the forearm. The splint was curved 
(pistol-shaped), and the surface which was applied to the arm was padded 



COLLES'S FRACTURE. 307 

•with care ; it was secured in place by a few light turns of a roller, and 
laid across the body in a sling. 

The arm was seen by me on each of the succeeding seven days, and 
on the third, fifth, and seventh days the splint was removed completely ; 
but on this last clay an erysipelatous inflammation had commenced in the 
neighborhood of the wrist. The splint and roller were therefore not re- 
applied, but the limb was laid upon a broad board, cushioned and cov- 
ered with oiled silk, and cool water irrigations were directed. The in- 
flammation soon subsided, but the splint was never resumed, as the frag- 
ments were found to stay in place perfectly without its aid. At the end 
of five weeks, union seemed to be consummated ; and one year later the 
bone was found to be perfectly straight, yet the wrist-joint and the finger- 
joints remained stiff, so much so that he was unable to perform any labor. 
The stiffness was, however, gradually disappearing, while all swelling 
and tenderness had long ceased. 

The observations of M. Voillemeir also have shown that, instead of 
being oblique, as has generally been supposed, the fracture is almost 
uniformly transverse from the palmar to the dorsal surfaces of the bone, 
and only occasionally slightly oblique in its other diameter, or from the 
radial to the ulnar side. I have seen, however, in the museum of the 
College of Physicians of Philadelphia, a specimen of this fracture in 
which the line of fracture is transverse, from side to side, but very ob- 
lique from before backwards, and from below upwards. There is also a 
line of incomplete fracture extending into the joint. It is united by 
bone, with the usual displacement backwards. 

The observations of both R. Smith and Voillemier have shown, more- 
over, that the displacement of the lower fragment is seldom sufficient to 
enable it to escape completely from the upper; and that where, in ex- 
tremely rare instances, and in consequence of extraordinary violence, 
such complete separation does occur, a disruption of those ligaments 
which attach the lower fragment to the ulna occurs also, and the deform- 
ity becomes at once very great, so that it no longer presents the peculiar 
features of Colles's fracture, but resembles a dislocation. 

In the so-called Colles's fracture, the lower and outer border of the 
radius, or its styloid apophysis, is swung around or tilted, as it were, 
upon the ulna ; the lower and inner border of the same fragment being 
retained in place by the radio-ulnar and internal lateral ligaments, which 
do not usually suffer a complete disruption, but only a stretching or par- 
tial laceration, possibly by the triangular ligament or by some of its un- 
torn fibres, and by one fasciculus of the anterior annular ligament, which 
is probably seldom torn. The upper or broken margin of the lower 
fragment, and also the ulnar margin, undergo very little displacement ; 
while the lower or articular surface, and the radial margin, are carried 
backwards, upwards, and outwards. 

Surgeons have spoken of a falling in of the upper end of the lower 
fragment toward the ulna, as an almost inevitable result of the action of 
the pronator quadratus, and against which tendency they have sought 
carefully to provide ; but there is much reason to believe that any con- 
siderable degree of displacement in this direction is a rare event, and 
that, when it does exist, it is in consequence mostly of the direction of 



308 FRACTURES OF THE RADIUS. 

the force which has produced the fracture rather than of the action of 
this muscle, only a few of the fibres of which are usually attached to 
the lower fragment, and, in some instances, when the fracture is within 
a half or quarter of an inch of the articulation, not any. Besides, there 
is actually in these latter cases no interosseous space into which the 
fragments may fall, and its displacement toward the ulna becomes, there- 
fore, impossible. 

Still, however, if one were disposed to speculate upon the condition 
of these parts after the fracture, it might perhaps be easy to persuade 
ourselves that the action of the pronator quadratus upon the upper 
fragment, whose broken extremity was not completely, or at all, disen- 
gaged from the lower, would carry both fragments together toward the 
ulna. But whatever might be the result of our speculations, still the 
fact, as proved by specimens, is not generally so ; and this is not the 
first time that facts and theories have disagreed. 

The truth is, that it is unusual to find any of the museum specimens 
of this fracture thus united. But they may be found constantly tilted 
back in the manner I have described, occasionally tilted forwards, and, 
still more rarely, slightly displaced upon their broken surfaces antero- 
posteriorly. 

The general absence of this internal displacement may find its ex- 
planation in the direction of the force which generally produces this 
fracture, in the occurrence of the fracture sometimes at a point so low 
as to render its displacement in this direction impossible, and in the 
breadth of the bone, at the seat of the fracture, which does not permit 
it to fall laterally without actually increasing its length ; a circumstance 
which its secure ligamentous attachment to the ulna at its opposite ex- 
tremities, and its complete apposition to the wrist and elbow-joint, do 
not alloAV. 

The mistake of those surgeons who have attempted to describe this 
fracture has originated in the appearance presented in nearly all recent 
fractures occurring at this point. The hand falls to the radial side, and 
seems to carry the lower end of the lower fragment with it, while the 
lower end of the ulna becomes unnaturally prominent in front and to 
the ulnar side ; a condition of things which has naturally enough been 
ascribed to the displacement of the upper end of the lower fragment in 
the direction of the interosseous space. 

But this same radial inclination of the hand, and prominence of the 
ulna, are present frequently when the radius is broken at its lower end, 
and no displacement in any direction has taken place ; and I have even 
observed it in simple sprains of the wrist, and in the hands of old or 
feeble persons where all the ligaments have become relaxed. 

It is seen, however, in a more marked degree when the bone is actu- 
ally both broken and displaced backwards in its usual direction. In 
short, the deformity in question is due, in a large majority of instances, 
to the relaxation, stretching, or more or less disruption of the anterior 
and posterior radio-ulnar ligaments, the triangular fibro-cartilages, and 
the internal lateral ligaments; to which, I feel satisfied, from the observa- 
tions of Dr. Pilcher, hereafter to be described, we must add the influ- 
ence of the strong and unbroken oblique fasciculus of the anterior carpal 



COLLES's FRACTURE. 309 

ligament described by him, and which, for the sake of convenience, I 
shall speak of as Pilcher's ligament. It is probably due to one or all of 
these circumstances combined that the hand falls to the radial side by a 
sort of rotatory motion, of which the unbroken external lateral ligaments 
and Pilcher's ligament constitute the axis or centre of motion. For this 
reason, also, because these triangular, internal, and radio-carpal liga- 
ments once lengthened or broken can never, or only after a lapse of 
many years, be completely restored, this deformity may be expected, in 
a certain number of cases, to continue, however exact and perfect may 
be the bony union. 

It must be added, however, that so long as the tilting of the fragment 
remains, the articular surface is actually presenting somewhat to the 
radial side. While in the normal condition it presents downwards, for- 
wards, and inwards, it now presents, when the displacement is consid- 
erable, downwards, backwards, and outwards. 

Diday maintained that there existed usually in this fracture an over- 
lapping or shortening of the bone in its entire diameter, and Voillemier 
thought that the specimens which he had examined proved that an im- 
paction was almost universal. 

Both of these opinions have been combated by Robert Smith ; the 
shortening observed by Diday being found only on that side of the bone 
to which the hand inclines, and being, according to Robert Smith, the 
result of the motion of the lower fragment already described ; and the 
appearance of impaction being due to the ensheathing callus, which is 
deposited usually, if the displacement is allowed to continue, in the re- 
tiring angle opposite the seat of fracture. 

These are questions, however, requiring for their decision a very 
careful study of specimens, and in relation to which farther observations 
may be necessary. Indeed, some recent observations made by Mr. 
Callender, of Saint Bartholomew's Hospital, London, go far to sustain 
the opinion of Diday, that some impaction generally exists, but rather 
upon the posterior margin than upon either the radial or ulnar side ; x 
and my own observations lead me to conclude that a posterior impaction 
is quite common. 

In a case reported by Dr. Cameron, of Glasgow, resulting in speedy 
death, the impaction was complete posteriorly, and was accompanied 
with impaction and comminution of the lower fragment, while the frac- 
ture in front was " hardly complete, the periosteum holding the frag- 
ments together." 2 

Comminution of the lower fragment has never occurred in the experi- 
ments made by me upon the cadaver, but it is quite common to meet 
with such examples in dead-house specimens, especially when the patients 
have fallen from a height and have been killed by the accident. Its 
existence usually implies the application of greater force than results 
from a fall upon the hand upon the sidewalk. The latter represents 
the usual accident, while a fall from a height is the exceptional accident, 
and the character of the fracture is therefore exceptional. 

1 Callender, St. Barth. Hosp. Rep., p. 281, 1865. 

2 Cameron, das. Med. Journ., March., 1878. 



310 



FRACTURES OF THE RADIUS 



In the accompanying woodcut (Fig. 91) is seen an impacted and 
comminuted fracture of the lower end of the radius. Dr. James Went- 
worth, of Troy, N. Y., who sent me the specimen, says that the patient, 
a man, set. 50, in .a fit of delirium, jumped from a third-story window, 
alighting upon the stone pavement. He survived the accident less than 
one hour. 

Fig. 92 is from a specimen presented to me by Dr .William Van Buren, 
and was found in an autopsy at the New York City Hospital. In this 
specimen there is comminution, without impaction or displacement. The 



Fig. 91. 



Fig. 92. 



Fig. 93. 






Impacted fracture. (Au- 
thor's collection.) 



Comminuted fracture. (Author's 
collection.) 



Bigelow's case of commi- 
nuted fracture of the lower 
end of the radius. 

line of separation between the upper and lower fragments is transverse, 
and the lower fragment is divided into five distinct pieces, each line of 
fracture involving the joint. 

One curious example of this form of fracture is reported by Dr. 
Bigelow, of Boston (Fig. 93). The patient had fallen, and, being 
otherwise seriously injured, ultimately died in the Massachusetts Hos- 
pital. At first he had only complained of lameness at the wrist, as if it 
had been severely sprained ; but at the end of several days the joint 
became swollen, and from the persistence of the swelling Dr. Bigelow 
was led to diagnosticate a stellate crack in the articulating extremity 
of the radius, he having met with a similar case two years before, when 
a patient with the same symptoms had died of other injuries, and ex- 
hibited a crack in the same place, but less extensive than in this case. 
There was found, in this last example, a star-shaped fissure on the 
articulating surface, without displacement. These fissures penetrated 
the shaft for an inch or more. Dr. Bigelow thought that the bones of 
the wrist acted as a wedge to spread the corresponding hollow of the 
articulating extremity, and that this specimen would explain the persist- 
ence of some cases of sprained wrist. 1 



Boston Med. and Surg. Journ., vol. lviii. p. 99. 



311 

Robert Smith has described a fracture occurring at the same point, 
and probably possessing nearly the same characters as Colles's fracture, 
in which the lower fragment is thrown forwards instead of backwards, 
and which has generally been the result of a fall upon the back of the 
hand. There is no such specimen, however, in any of the pathological 
collections in Dublin, nor has Mr. Smith ever seen a specimen obtained 
from the cadaver, although he reports a case which fell under his obser- 
vation in practice. 

I have myself seen one such case, 1 but I regret to say that my exam- 
ination of the condition of the arm was not such as to enable me to give 
a very satisfactory account of the cause and symptoms of the accident. 
Referring, however, to the experiments upon the cadaver detailed in the 
succeeding pages, it will be seen that I have been able to produce this 
fracture by forced palmar flexion of the hand. 

Xelaton observes that all the varieties of this fracture which he has 
seen are often accompanied with fracture of the styloid apophysis of 
the ulna^ and with a tearing of the triangular ligament. I am not 
aware that any other writer has made the same observation in relation 
to the frequent occurrence of a fracture of the styloid apophysis of the 
ulna, and I think the accident is not so common as the remark of Nekton 
would lead us to suppose. 

Dr. Butler, House Surgeon to the Brooklyn Hospital, reports a case 
treated by Dr. J. C. Hutchison of fracture of the right radius at the 
junction of the middle and lower thirds, accompanied with a fracture 
also of the styloid apophysis in the same bone. The accident occurred 
in a lad fourteen years old, who had fallen from a height of thirty feet 
upon the pavement. The lower fracture commenced at the base of the 
styloid process of the radius, and extended down obliquely into the 
wrist-joint, breaking off about one-fifth of the articular surface. The 
process was drawn up on the posterior surface of the radius, about one 
inch and a half, by the supinator radii longus muscle. It was movable, 
but, in consequence of the contusion and swelling, could not be returned 
to its place. The hand occupied the same position that it does in Colles's 
fracture. 

On the eighth day an attempt was made to force down the process 
with a compress secured by adhesive plaster straps ; but it could not 
be done. The hand and arm were confined also to a pistol-shaped 
splint ; ulcerations ensued from the pressure of the compress, and the 
process was laid bare, but it finally became united in its abnormal 
position ; the motions of the wrist, however, were not impaired, and 
the power of pronation and supination soon returned. 2 

In January, 1879, a lady called upon me having a fracture of the 
styloid process of the radius, which had occurred about four months 
previously. The fragment was tilted forwards and carried slightly 
upwards by the action of the long supinator. It was movable. The 
motions of the joint were in no way interfered with, and the form of the 
wrist was natural. She was somewhat advanced in life, and suffered 

1 Trans. Am. Med. Assoc, vol. ix. p. 145. 

2 New York Journ. of Med., 1857. 



312 FRACTURES OF THE RADIUS. 

some from pains and soreness about the joint, but no more than is usual 
after severe wrist-joint injuries. The character of the accident was not 
recognized by her surgeon, and no treatment had been adopted ; nor is 
it to be supposed that the displacement could have been remedied, except 
by section of the tendon of the long supinator, if its existence had been 
recognized ; and, if this had been done, I doubt whether she would have 
had a more useful arm than she has now. 

I believe I have seen two examples of a fracture commencing on the 
radial side of the bone and terminating in the joint, the separated frag- 
ment including considerably more than the styloid process ; but neither 
of these cases has been verified by an autopsy. They were described 
in detail in the third edition of this book. 

In my experiments upon the cadaver, hereafter to be treated, the sty- 
loid process of the radius has been broken off twice at its base. 

Recently, Dr. E. Moore, of Rochester, N. Y., has demonstrated, by 
examinations upon the cadaver and by experiment, that in a certain pro- 
portion of cases the internal lateral ligament, and the triangular fibro- 
cartilage give way under the force which has occasioned the fracture, 
the styloid process is thrust under or through the annular ligament 
and imprisoned ; in fact, the ulna becomes dislocated, and is retained by 
the annular ligament in its new position ; this dislocation being accom- 
panied in some cases with a fracture of the styloid process of the ulna. 
Nor can the reduction of the fracture of the radius be accomplished until 
the ulna is released from its imprisonment. Reduction is to be accom- 
plished by extension and partial circumduction ; the hand being grasped 
firmly and extended first to the radial side, then backwards to the ulnar 
side, and finally forwards, or in the position of flexion. During the 
entire manoeuvre the wrist is held firmly by the opposite hand of the 
surgeon. The test of reduction is to be found in the presence of the head 
of the ulna on the radial side of the ulnar extensor. 

In order to retain the ulna in place when reduction is effected, Dr. 
Moore places a thick, firm compress over its lower end, on the palmar 
and ulnar margins of the forearm, and secures this in place with a broad 
band of adhesive plaster drawn firmly around the wrist. The forearm 
is then placed in a narrow sling passing under the wrist and compress. 
This completes the dressing. 1 The five examples presented by Dr. Moore 
and verified by an autopsy, must be regarded as exceptional cases ; all 
of them being results of falls from a considerable height, and most of them 
have proved speedily fatal, thus affording an opportunity for post-mortem 
inspection. They are not fair representatives of that class of cases which 
are caused by falls upon the hand in the street, and which have been 
regarded as typical cases. Dr. Moore concludes, however, from autop- 
sies, and from personal observation of other cases, that " luxation of the 
ulna exists in more than half of the cases." But I was never able to pro- 
duce it in any of my experiments upon the cadaver ; that is to say, the 
extensor carpi ulnaris was never dislodged from its groove, and this is 
what he considers essential to the luxation. By the change of position 
of the lower fragments of the radius and ulna the extensor carpi ulnaris 

» Moore, New York Med. Rec, April 1, 1870 ; March 20, 1880. 



COLLES'S FRACTURE. 313 

is less distinctly felt, or it cannot be felt at all, but the dissection always 
shows that it remains in its groove. Indeed I feel persuaded that it 
cannot be torn from its normal position except by great force, such as was 
applied in all the cases mentioned by Dr. Moore. I shall refer to this 
matter again in connection with dislocation of the ulna. 

In the first volume of the Philadelphia Medical Examiner (1838) will 
be found a description, by J. Rhea Barton, of Philadelphia, of a form 
of fracture occurring through the lower end of the radius, which is prob- 
ably much less common than Colles's fracture, and which had hitherto 
escaped the notice of surgeons. Its peculiarity consists in the line of 
fracture extending very obliquely from the articulation, upwards and 
backwards, separating and displacing the whole or only a portion, as the 
case may be, of the posterior margin of the articulating surface. I have 
not recognized this fracture in any instance which has come under my 
own observation, nor have I been able to find a cabinet specimen in any 
pathological collection. Dr. Barton was not able to prove the correct- 
ness of his diagnosis by an autopsy, and the only well-authenticated 
example which I can find upon record is that to which Malgaigne has 
alluded to, as having been seen by M. Lenoir, and of which an account 
was published in the Archives Generates de Medecine, in 1839. M. 
Lenoir believed it to be a simple luxation of the hand backwards, but 
the patient having died, he was able to correct his diagnosis by an 
autopsy. A considerable fragment had been broken from the posterior 
lip of the articular surface, the line of fracture being from below upwards, 
and from before backwards. This fragment had become displaced up- 
wards and backwards, carrying with it the carpal bones, and producing 
thus the appearance of a simple dislocation. 1 I believe that the accident 
so carefully described by Barton was either a Colles's fracture, or a frac- 
ture simply of the radial margin, of which I have given two supposed 
examples, with the usual signs of which his account so exactly coincides, 
and that it was not a fracture of the posterior lip of the articulating sur- 
face, as he believed. 

As to the precise mechanism of this accident — speaking now only of 
the well-characterized Colles's fracture — there can be very little doubt. 
In a large majority of examples it is the result of two forces acting in an 
opposite direction, one being the weight of the body in falling, and the 
other the impact or resistance of the ground, the bone giving way, as is 
usual in other long bones, nearest the point of impact, where, owing to 
the unyielding nature of the resistance as compared with the yielding 
nature of the impulse (or weight of the body), the vibration is the greatest ; 
and in this particular case, the fracture is not only almost always in the 
lower end of the bone, but also at or near that point where the bone is 
less strong than elsewhere, namely, where the compact tissue ends and 
the more spongy tissue commences. 

According to Malgaigne, this view of its mechanism was illustrated 
experimentally by M. Nelaton. Having amputated the forearm upon a 
cadaver, and sawn off the olecranon process, he placed the palm of the 
hand upon a solid surface, the forearm being vertical, and then struck a 

1 Malgaigne, Traite cles Frac., etc., torn. ii. p. 700. 
21 



314 



FRACTURES OF THE RADIUS 



heavy blow upon the upper end of the two bones. Upon dissection he 
found the radius broken transversely near its lower end, the lower frag- 
ment being tilted backwards. 

I have repeated this experiment, and with the same result. It is not 
easy, however, to produce the fracture in this way upon the cadaver, 
unless we select the bones of young persons or delicate women for the 
experiment; the force required to cause the fracture being greater than 
is required in the living subject, because the muscles are relaxed and the 
stability of the bones is not well maintained. 

In a few cases also the mechanism of the fracture will admit of another 
explanation. A Colles's fracture has been caused in the living subject 
by simply forcing the hand strongly backwards, and without a fall or 
sudden impact. Thus Yoillemier relates that he had seen the fracture 
once caused by a fall upon the lower half of the hand, in which the heel 
of the hand did not touch the ground ; but another case was even more 
conclusive, the fracture being caused by forced flexion (probably "dorsal 
flexion") made by a comrade. According to Malgaigne, M. Bouchet 



Fig. 94. 



Fig. 95. 





Transverse fracture of the lower end of the ra- Transverse fracture of lower end of radius; 

dius ; caused by forced palmar flexion ; in the caused by forced dorsal flexion ; in the cadaver, 
cadaver. A. Internal lateral ligament. B. Third fasciculus 

(Pilcher's) of anterior carpal ligament. C. Anterior 
radio-ulnar ligament. 

was the first to observe this mode of causing the fracture ; his observa- 
tions having been made exclusively upon the cadaver. In trying to dis- 
locate the wrist, he found he could. produce only a fracture of the lower 
end of the radius, sometimes with other lesions, and especially with frac- 
ture of the styloid process. 1 

Recently, Dr. Lewis A. Pilcher, of Brooklyn, N. Y., has called atten- 



Bouchet, These sur les lux. du poignet, Paris, July, 1834. From Malgaigne. 



COLLES S FRACTURE. 



315 



tion to the mechanism of fracture of the radius at its lower end by forced 
palmar or dorsal flexion, or by cross strain. He has made a large num- 
ber of experiments upon the cadaver, and some of his conclusions are 
very important. He has observed that when the cross strain, causing 
the fracture, in forced dorsal flexion is very great, and the lower frag- 
ment is much tilted back, the periosteum on the dorsal surface, reinforced 
by a certain amount of aponeurotic fibres, is torn or lifted from the 
radius, and thus allows the lower fragment to ride backwards, and be- 
come impacted upon the posterior edge of the upper fragment. 

Dr. Pilcher has also observed that the chief cause of the peculiar posi- 
tion assumed by the hand after this fracture was the presence of " a 
strong oblique fasciculus of the anterior ligament of the wrist, which 
extended from the cuneiform bone to the anterior border of the styloid 
process of the ulna. By the backward displacement of the carpus, and 
the attached radial fragment, that ligament was put upon the stretch, 
limiting all motion until relaxed." 1 

It will be seen that Dr. Pilcher attributes nothing of the peculiar phe- 
nomena to the integrity of the internal lateral, triangular, and radio- 
ulnar ligaments ; but to my mind it is very plain that this view of the 
subject is too exclusive, and that whenever these latter ligaments remain 
untorn they contribute to the malposition of the hand. 

I have repeated these experiments of Bouchut and Pilcher now many 
times upon the cadaver ; and while they confirm in a great measure the 
observations of Pilcher, they also pre- 
sent some other curious facts. There is, 
for example, a considerable variation in 
the results as to the exact seat and nature 
of the lesion. 1st. In some there is only 
a laceration of the anterior annular liga- 
ment of the wrist, which, occurring in the 
living subject, would pass for a sprain of 
the wrist. 2d. The styloid process of the 
radius is alone broken off at its base. 3d. 
The anterior lip of the radius is sometimes 
broken off, the line of fracture being trans- 
verse, but not involving the whole thick- 
ness of the bone. 4th. The line of frac- 
ture is occasionally oblique from the ulnar 
to the radial side of the radius, commenc- 
ing outside of the joint and terminating 
in the joint. 5th. The line of fracture is 
generally transverse, involving the entire 
thickness of the bone, and from half to 
three-fourths of an inch above the joint. 
In these examples there is a slight obli- 
quity in the direction from before back- 
wards and upwards, as would naturally 
occur in fracture from avulsion, when the 



Fig. 9b'. 




Fracture at base of styloid process of 
radius, and laceration of annular liga- 
ment ; caused by forced dorsal flexion ; 
in the cadaver. 






1 Pilcher, Paper read before the New York Acad. Med., May 16, 1878. The Med. 
Record, July 27, 1878, p. 74. 



316 FRACTURES OF THE RADIUS. 

active force was applied to the lower fragment. 6th. Pilcher's ligament 
is always untorn, while rupture of the radio-ulnar, triangular, and in- 
ternal lateral ligament is occasionally found. 7th. In some cases there 
is a mere fissure or crack of the bone, not extending through its entire 
thickness, and which could not have been recognized in the living subject. 
8th. In others it is more or less tilted or pressed back, but not overlapped ; 
and these constitute a majority of the whole, and these were easily re- 
placed in their natural position by simply pressing the lower fragment 
forwards, as has been my practice in many cases hitherto. 9th. When 
the force applied is greater or longer continued the lower fragment is 
displaced backwards upon the upper, the periosteum is torn up pos- 
teriorly; and there would be impaction, no doubt, if the muscles had 
their normal power of contraction, or if added to the cross strain there 
had been the driving force of a fall upon the palm of the hand; and in 
these cases it was difficult to tilt the lower fragment forwards into line 
without first relieving the strain upon this periosteal ligament by the 
method described by Pilcher. 10th. The character of the lesions in the 
opposite wrists of the same cadaver was generally symmetrical ; the same 
lesion being caused by the same manipulation in one arm as in the other. 
11th. Fractures nearly identical with Colles's fractures were produced 
by forced palmar flexion, but not quite so readily. 

These are the facts as observed by me in the dead-house experiments, 
and no doubt they illustrate to some extent the mechanism of this ac- 
cident as it occurs in life ; but it is apparent that in some respects the 
circumstances differ. There is in the case of the cadaver no muscular 
contraction to give fixedness to the bones, and to displace the fragments 
after they are separated, or to maintain them in a position of displace- 
ment. The force of sudden impact caused by the weight of the body 
in falling is not present. In short, the fractures caused by the experi- 
ments were the result solely of the action of the carpal ligaments upon 
the lower ends of the bones; they were fractures by avulsion or cross 
strain, while in the examples presented in the living subject they are 
usually the result of avulsion, concussion, and muscular action combined, 
of which causes perhaps the cross strain is not the least efficient. 

One hundred and five examples of Colles's fracture have furnished no 
cases of non-union, nor indeed do I remember ever to have seen the union 
delayed ; but in a pretty large proportion of cases occurring in the prac- 
tice of surgeons whose patients have been brought under my notice, some 
slight or considerable deformity remains, and in most cases the joint 
remains more or less stiff and sensitive for some months. In one exam- 
ple, the case of a man whose arm was broken in Germany, when he was 
only ten years old, the fragments of the radius were driven into each 
other, or overlapped one inch, and the ulna had been displaced down- 
wards toward the fingers the same distance. This was examined twelve 
years after the accident, and he had then a very useful arm. Twice I 
have found the wrist and finger-joints quite stiff after a lapse of one year; 
in one case I have found the same conditions after two years, in one case 
after three years, and in two cases after five years. 

In cases treated by myself, where I have exercised great care in 
reducing the fragments thoroughly, and where the bandages and splints 



COLLES'S FRACTURE. 317 

have not been applied too tightly, nor kept on too long, deformity to any 
considerable extent is the exception, and the stiffness is soon dissipated. 
I say it has been the exception, not intending to claim that under my 
care considerable deformity has never resulted. 

Confining our remarks still to Colles's fracture, the deformity which 
has been observed most often, after the lapse of several months or years, 
is a projection of the lower end of the ulna inwards, a phenomenon ex- 
plained fully in the preceding pages. Rarely it is displaced backwards, 
and still more rarely forwards. In a majority of cases this is accompa- 
nied with a perceptible falling of the hand to the radial side, while in a 
few it is not. After this, in point of frequency, I have met with the 
backward inclination of the lower fragment. Robert Smith found this 
displacement almost constant in the cabinet specimens examined by him ; 
and it is very probable that nearly all of the specimens examined by 
myself would present more or less of the same deviations upon the naked 
bone ; but in the living examples a slight deviation would be concealed 
by the numerous tendons which cover this part of the arm, and perhaps 
by some permanent effusions, of which I shall speak more particularly 
presently. 

There remains for a long time, in many cases, a broad, firm, uniform 
swelling on the palmar surface of the forearm, commencing near the upper 
margin of the annular ligament and extending upwards two inches or 
more. This swelling continues much longer in old and feeble persons 
than in the young and vigorous. It is pretty generally proportioned to 
the amount of anchylosis existing at the wrist and finger-joints, and it 
disappears usually pari passu with these conditions. There can be no 
doubt that this phenomenon is due to effusions along the sheaths of the 
tendons, and in the areolar tissue external to the sheaths, and it is as 
often present after sprains and other severe injuries about this part, as 
in fractures. In many cases, however, its prolonged continuance and its 
firmness have led to a suspicion that the bones were displaced, a sus- 
picion which only a moderate degree of care in the examination ought 
easily to dispel. A similar effusion, but in less amount, is frequently 
seen also on the back of the hand, below the annular ligament. When 
both exist simultaneously the appearances of deformity and of displace- 
ment are greatly increased. Here, then, we shall find a partial expla- 
nation of the anchylosis in the wrist and finger-joints, which continues 
occasionally many months, or even years, if, indeed, it is not permanent; 
an anchylosis produced in a few instances by extension of the inflamma- 
tion to these joints, but much more often by the inflammatory effusion 
and consequent adhesions along the thecse and serous sheaths, through 
which the tendons all pass in their course to the hands and fingers, and 
also by simple contraction of the articular ligaments, as a consequence 
of disuse, or, as it is usually termed, by passive contraction of these lig- 
aments. The fingers are quite as often thus anchylosed after this frac- 
ture as the wrist-joint itself; a circumstance which is wholly inexplicable 
on the doctrine that the anchylosis is due to an inflammation in the 
joints. Indeed, I have seen the fingers rigid after many months, when, 
having observed the case throughout myself, I was certain that no inflam- 
matory action had ever reached them. 



318 FRACTURES OF THE RADIUS. 

The peculiar swellings of the wrist and hand which have been de- 
scribed above, commence to show themselves very early after the receipt 
of the injury ; but I have noticed, also, a swelling which is a little later 
in its accession, namely, an induration and fulness upon the back of the 
hand, which corresponds accurately to the position of the carpal bones, 
and presents an appearance as if all the carpal bones were slightly dis- 
placed backwards. This phenomenon is probably clue to a swelling and 
induration of the numerous ligaments which bind together these bones 
posteriorly. It usually disappears after a few months. 

Nor is it any more difficult to show, I think, that the anchylosis of the 
wrist-joint is not often due to a malposition of its articular surfaces, as 
has frequently been asserted in the written treatises. 

The most superficial examination of the mechanism of this joint ought 
to satisfy us, that any moderate or even considerable malposition of the 
lower fragment after a fracture of the radius, is not sufficient in itself 
to occasion anchylosis. It is true that in the fracture now under con- 
sideration, the direction of the articular surface of the radius is often 
changed, and that, while it was directed downwards, forwards, and to 
the ulnar side, it is now, perhaps, directed downwards, backwards, and 
to the radial side. But of what consequence is this so long as the carpal 
bones, with which alone this bone is articulated, preserve their relations 
to the radius unchanged ? 

If any other evidence be demanded, it may be supplied by the expe- 
rience of most surgeons in examples of anchylosis without displacement ; 
in examples of displacement without anchylosis, but in which the anchy- 
losis has yielded gradually to the lapse of time, while the displacement 
has continued. The following case is in point : James Ryan, a private 
in the 15th N. Y. Volunteers, fell from a height into a ditch during the 
battle of Fair Oaks, Va., May 31, 1862, striking upon the palm of his 
left hand, and causing a simple fracture near the lower end of the radius, 
accompanied probably with impaction. I do not know what treatment 
was adopted, but when he came under my observation, in March, 1863, 
at the Central Park General Hospital, New York, I found the most ex- 
traordinary deflection of the hand to the radial side which I have ever 
seen after this fracture. The hand could be turned laterally, to a right 
angle with the arm ; yet the motions of flexion and extension at the 
wrist-joint were nearly as perfect as in the opposite arm, and the hand 
was in all respects as useful as before the accident. 

To what I have said as to the prognosis in these accidents, I may be 
permitted to add the opinion of our distinguished countryman Dr. Mott, 
given in a clinical lecture before his class in the University of New 
York. 

" Fractures of the radius within two inches of the wrist, where treated 
by the most eminent surgeons, are of very difficult management so as to 
avoid all deformity ; indeed, more or less deformity may occur under 
the treatment of the most eminent surgeons, and more or less imperfec- 
tion in the motion of the wrist or radius is very apt to follow for a longer 
or shorter time. Even when the fracture is well cured, an anterior 
prominence at the wrist, or near it, will sometimes result from swelling 
of the soft parts." 



COLLES'S FRACTURE. 319 

To which the reporter, himself a surgeon in the city of New York, 
adds : — 

"As the above opinion of Professor Mott coincides with my own 
observations, both in Europe and in this city, as well as with many of 
our most distinguished surgical authorities, I venture to hope that it 
may assist in removing some of the groundless and ill-merited asper- 
sions which are occasionally thrown on the members of our profession 
by the ignorant or designing." 1 

In evidence that we have not yet attained all that we could desire in 
the treatment of this fracture, I will quote farther: — 

" In young subjects, fractures of the lower end of the radius are 
easily reduced, unite readily, and leave the use of the limb perfectly 
unimpaired ; but in old persons, who, as before stated, are especially 
liable to this injury, the result is often most unsatisfactory, even after 
the greatest care has been used during the treatment. It is frequently 
months before the hand is free from pain and regains its proper motions, 
and too often an unsightly, crooked, and permanently stiff wrist remains, 
to the great inconvenience and annoyance of the patient." 2 

" Union occurs in about a month, but rarely without some displace- 
ment." 3 

" In a large number of cases it is impossible to loosen the impacted 
fragments." 4 Ashhurst and Gross express similar opinions. Let me 
add that several cases treated lately, under my observation, by the 
plaster-of-Paris and by Moore's method, both of which have recently 
been much employed in this country, have given no better average re- 
sults than have been obtained by other methods. 

Of gangrene as an occasional result of this fracture, I shall speak 
presently, in connection with the subject of treatment. 

The peculiar character of the displacement which characterizes 
Colles's fracture, and the constant difficulty experienced by surgeons in 
obviating deformity, have led to much speculation and ingenious inven- 
tion ; and modern surgeons, especially, have thought it necessary to 
introduce here an essential modification of the usual apparel for broken 
forearms. This modification consists in employing a pistol-shaped 
splint, instead of a straight splint, by means of which the hand may be 
thrown more or less strongly to the ulnar side. 

Heistei 5 speaks of inclining the hand toward the ulna, while reducing 
a fracture of the radius, but when the reduction has been effected he 
recommends a straight splint. 

Among the first to advocate the permanent confinement of the hand 
in this position, were Mr. Cline, 6 and M. Dupuytren. 7 Mr. Cline, and 

1 Boston Med. and Surg. Journal, vol. xxv. p. 289. 

2 Holmes's System of Surgery, American ed., 1870, vol. ii. p. 798. 

3 Grant's System of Surgery, London, 1871, p. 463. 

4 Bryant's Surgery, London, 1872, p. 937. See also opinion of Callender on same 
page. 

5 De Lavrentii Heisteri, Institutiones Chirurgicse, pars prima, p. 203, Amsterdam 
ed., 1739. 

6 Malgaigne, Traite de Frac., etc., torn. i. p. 614, Paris ed. 

7 Dupuytren on Bones, London ed., p. 140. 



;20 



FRACTURES OF THE RADIUS. 



after him Bransby Cooper, 1 and Mr. South, 2 recommend the ordinary 
straight splints for the forearm, but the rollers by which the splints are 
secured in place are not permitted to extend lower than the wrist ; so 
that when the forearm is suspended in a sling, in a state of semi- prona- 
tion, the hand shall fall by its own weight to the ulnar side. 

Dupuytren, and after him, Chelius, adopt, in addition to the palmar 
and dorsal splints, the " attelle cubitale," or ulnar splint ; which is a 
gutter, composed of steel, iron, tin, or some other metal, and made to 
fit the ulnar margin of the forearm and hand, when the hand is drawn 
forcibly to the ulnar side. Blandin, 3 Nelaton, 4 and Goyraud, 5 also, 
under certain contingencies employ the same. 

Most surgeons, however, employ either a palmar or a dorsal splint ; 
or both palmar and dorsal splints constructed with a knee, or pistol- 
shaped, and they thus avoid the necessity of the ulnar splint. Thus, 
Nelaton, 6 Robert Smith, 7 and Erichsen, 8 recommend this peculiar form 
only in the dorsal splint ; while Bond, 9 Hays, 10 E. P. Smith, 11 G. F. 
Shrady, 12 and others, especially among the Americans, place the pistol- 
shaped splint against the palmar surface of the forearm and hand, 



Fig. 97. 




Ne'laton's splint for fracture of the radius. 



A few modern surgeons have not seen fit to adopt this peculiar prin- 
ciple of treatment, or this form of dressing under any of its modifica- 
tions. Colles 13 recommends a straight palmar and dorsal splint, and does 
not incline the hand. Barton 14 advises the same, and Skey, having de- 
clared his preference for a couple of broad, straight splints, adds : 
" Great care should be taken to prevent the hand falling, and this object 



1 B. Cooper, Lectures on Surg., p. 232, American ed 

2 Chelius's Surg., vol. i. p. 613. 

3 Malgaigne, op. cit., torn. i. p. 614. 

4 Nelaton, Elem de Path. Chir., torn. i. p. 747. 

5 Ibid., p. 746. 
7 R. Smith, op. cit., p. 168. 
9 Bond, Amer. Joura. Med. Sci., April, 1852. 

11 E. P. Smith, Buffalo Med. Journ., vol. ix. p. 225 

12 Shrady, Am. Med. Times, 2 cases, Dec. 22, 1860. 

13 Colles, Lectures on Surgery, p. 325. 
i* Barton, Phil. Med. Exam., 1838. 



6 Nelaton, op. cit., p. 747. 
8 Erichsen, Surgery, p. 215. 
i° Ibid., Jan. 1853. 



COLLES'S FRACTURE. 



321 



will be attained by inclosing the entire forearm and hand in a well- 
applied sling." 1 

Stephen Smith employs two broad, straight, palmar and dorsal splints, 



Fig. 98. 




Bond's splint. 



secured in position by adhesive strips, the hand being thrown to the 
ulnar side by reversed turns of adhesive plaster. 



Fig. 99. 




Hay's splint. 

Professor Fauger, of Copenhagen, has undertaken to treat this frac- 
ture in some sense without any splint, the forearm and hand being 
simply laid over a double inclined plane, so as to bring the wrist into 
a state of forced flexion. " The hand having been brought into a posi- 
tion of strong flexion, the forearm is placed, pronated, on an oblique 
plane, with the carpus highest, the hand being permitted to hang freely 
down the perpendicular end of the plane." 2 M. Velpeau, in a report 

Fig. 100. 




E. P. Smith's splint. Surface applied to forearm. A. Forearm piece, made of felt, with 
incurvated margins. 

of his surgical clinic at La Charite for the year ending September, 
1846, says this plan has been tried during the year, and " the result has 



Skey, Operative Surgery, p. 161. 



2 Fauger. London Lancet, May 8, 1847. 



322 



FRACTURES OF THE RADIUS. 



not been very satisfactory. The experiment, however, has not been 
decisive upon this mode of treatment." 1 



Fig. 101. 




E. P. Smith's splint. B. Opposite surface. D, the hand-block, is connected with the forearm piece 
by two circular brass plates, which move upon each other, in order that the hand-block may assume 
any desired angle with the arm. In this way it may be adapted to either the right or left arm. It is 
fixed by a nut, seen on the brass plate. The letters C indicate the extent of motion allowed to the 
hand-block. 

The late Henry S. Hewit, of this city, devised a very ingenious splint, 
by which the mobility of the wrist and fingers might be more perfectly 
retained, and the wrist put into any desirable position. The following 
is the description given by himself of the apparatus : " The wooden 
ball grasped by the hand is connected by a rod to a slender bar running 
longitudinally upon the face of the splint, and capable of being flexed at 
any desirable length. The rod is attached to the travelling connection 
by a universal joint, giving play to the ball in limited movements of flex- 

and supination. The natural tendency is for 



ion, extension, pronation, 



Fig. 102. 




the patient to make these movements, and to perpetually relax and con- 
tract the fingers. The splint upon the inner surface of the arm is antago- 
nized by a plain flap-splint on the outer surface, extending to the supe- 
rior border of the wrist-joint. This splint has been used for upwards of 
two years by myself and others, particularly by Dr. W. T. White, at 
the Demilt Dispensary, and has given good results." 2 

We come now to consider how far this peculiar treatment, ulnar incli- 
nation, is capable of answering the special indications of the case we are 
studying. 



1 Velpeau, Boston Med. Journ., vol. xxxv. p. 213. 

2 Hewit, Medical Record, April 1, 1873. 



COLLES'S FRACTURE. 323 

It is assumed, as I have already intimated, that, by bearing the hand 
strongly to the ulnar side, the fragments of the radius are brought more 
exactly into apposition, and more easily and effectually retained ; an 
assumption which supposes two things to have been determined : first, 
that there exists an overlapping of the fragments, either through the 
whole extent of their broken surfaces or especially toward the radial side, 
or that the upper end of the lower fragment is inclined to fall against 
the ulna, or that all of these several conditions coexist ; and, secondly, 
that if such displacements do exist, they can be remedied by this 
manoeuvre. 

The first of these suppositions seems to have been sufficiently con- 
sidered by all those gentlemen who have particularly examined the 
specimens contained in the various pathological collections, and to whose 
careful investigations I have already frequently adverted. With rare 
exceptions, none of these displacements have been found to exist, although, 
as has been observed, a. casual inspection of the arm when recently 
broken would often lead to an opposite conclusion. I do not here speak 
of impaction, which is usually upon the posterior margin, if it exists at all. 

In regard to the second supposition, namely, that, where such dis- 
placements do exist, a forced adduction will aid in the retention of the 
fragments, I shall have to speak more cautiously, because, so far as I 
know, my opinions have received as yet no public and authoritative 
indorsement. In order that adduction may prove effective, there must 
be some point upon which to act as a fulcrum. It is of no use that we 
rotate the hand for the purpose of making extension unless there can be 
found a resistance or fulcrum upon which the rotary motion may be 
performed. Such a fulcrum exists, no doubt, but to determine its availi- 
bility we must ascertain its character and position. 

It is not in the lower end of the ulna, for the ulna has no point of 
contact with the carpal bones, and when, in the natural state of these 
parts, the hand is inclined to the ulnar side, the lower end of the ulna 
rides freely doAvnwarcls upon the wrist until arrested by the ligaments 
which unite it with the carpus, or by the capacity of the joint to admit 
of motion in this direction. When the lower end of the radius is broken, 
and the ligaments of the joint are more or less torn, the ulna, although 
thrust downwards much farther perhaps than it could ever descend in 
its normal state, still fails to find a support, and spreading wider and 
wider from the radius as it is thrust further upon the hand, no limit 
can be given to its progress in this direction. It was thus that, in one 
example already mentioned, I found the ulna carried downwards one 
inch or more, and this was the fact in several cases reported by Moore, 
and verified by the autopsy. 

The resistance will, then, in nearly all cases, be found to be in those 
ligaments which bind the lower fragment to the lower end of the ulna, 
and the ulna to the carpal bones, viz., the radio-ulnar, the triangular, 
and the internal lateral ligaments, which in the normal state of the parts 
constitute the centre upon which forced adduction expends its power, 
and which still continue to be the point of resistance when the radius is 
broken. But how feeble and uncertain must be a resistance which 
depends solely on these injured and often lacerated ligaments I And 



324 FKACTURES OF THE RADIUS. 

how painful to the patient must be an extension sufficient to overcome 
the action of nearly all the muscles of the wrist, which is borne entirely 
by a few torn and inflamed fibres! even in health this position, when 
forced, cannot be endured beyond a few seconds, and it must be difficult 
to estimate the sufferings which the same position must occasion when 
the ligaments are torn and inflamed. 

I am not to be told that surgeons have not intended to advocate this 
extreme practice ; that they have never recommended forced adduction, 
but only a moderate and easy lateral inclination, such as can be com- 
fortably borne. If they have not, then they should not have spoken of 
making extension by this means. An easy lateral inclination has no 
power to do good so far as extension is concerned, any more than it has 
power to do harm. But the fact is, while a majority of surgeons have 
no doubt used less force than was hurtful, some have used more than 
was useful or safe ; indeed, the sharpness of the curve given to the 
splints figured and recommended by Dupuytren, Nelaton, and others, 
sufficiently indicates that their distinguished inventors intended to accom- 
plish by these means a forced and violent adduction. 

Malgaigne, speaking of other means of extension applied to the fore- 
arm, suggested by Godin,Diday, and Velpeau, intended to operate only 
in a straight line, and alluding especially to the modes devised by Huguier 
and Velpeau, remarks: "Without discussing here the comparative value 
of the two forms of apparatus, I believe that they could scarcely be 
endured by the patients ; and M. Diday tells us that in the trials which 
he has made, the pain produced by the extension was so great that he 
was compelled to renounce it." Which observations cannot but apply 
equally to this plan of extension by adduction or to any other which 
might be adopted. Dr. G. S. Porter, of Lonaconing, Maryland, has 
used for the purpose of extension a padded wire-splint applied to the 
dorsal surface of the arm and hand, and in which the extension is sup- 
posed to be effected by adhesive plaster strips. 1 Notwithstanding the 
testimony which the experience of this gentleman has furnished of the 
value of this method, and not doubting that he obtained satisfactory 
results, I must be permitted to say that probably they were due to the 
thoroughness with which he reduced the fracture in the first place, 
rather than to the efficiency of the apparatus ; and I will take this 
opportunity of saying that the success of Drs. Moore and Pilcher, neither 
of whom employ splints, depends, in my opinion, wholly upon the fact 
that they have had the good judgment and skill to reduce the fragments 
effectually in the first instance, after which, as I have already said, 
there is usually very little probability that they will become displaced. 

After all, it must not be inferred that I have concluded to reject this 
mode of dressing — the pistol-shaped splint — in all of its modifications ; 
for, although I am far from being persuaded of its utility as a means of 
extension and retention in any case, yet I am not prepared to deny to 
it some very considerable value in another point of view ; and when 
judiciously employed it can certainly do no harm. It is, I repeat, for 
another reason altogether than the one heretofore assigned, that I would 

1 Porter, Med. and Surg. Reporter, April 14, 1877. 



COLLES's FRACTURE. 325 

recommend its continuance, a reason which I cannot so well explain, or 
hope to render intelligible, except to the practical surgeon. This posi- 
tion throws the whole lower end of both radius and ulna outwards toward 
the radial margin of the splints, and by keeping the radius more com- 
pletely in view, it enables the surgeon better to judge of the accuracy 
of the reduction, and to recognize more readily the condition and situa- 
tion of the compresses, etc. This alone I have always considered a 
sufficient ground for retaining the angular splint : although I have treated 
a great number of arms satisfactorily with the straight splints alone. 

Finally, while surgeons have been seeking to meet an indication, the 
existence of which is at least rendered doubtful, and by means which 
appear to me totally inadequate, if it did exist, they have probably too 
often overlooked or regarded indifferently an indication which is almost 
uniformly present, namely, to press forwards the tilted fragment by a 
force applied upon the wrist from behind, and to retain it in place by 
suitable compresses. And I cannot help thinking, that, if they had 
regarded this as the sole indication in most cases, an indication generally 
so easily met, they would have made fewer crooked arms, and have 
saved their patients much suffering and themselves much trouble. 
Some of the cases which I have reported in the early part of this chapter 
are intended to illustrate the value of this principle. 

In other, and somewhat exceptional cases, where the lower fragment 
is driven back until its broken surface overrides the broken surface of 
the upper fragment, and in addition to the consequent impaction there 
is added a lifting of the periosteum, as described by Pilcher, we must 
first, as stated by him, increase the dorsal flexion, press the finger 
against the proximal end of the lower fragment, and then, while making 
extension from the hand, gradually bring the hand and the lower frag- 
ment forwards. And I may add that if, by the method of direct and 
forcible pressure from behind, or by Pilcher's modification of this 
method, we have once brought the lower fragment thoroughly into place, 
it will remain in place with little or no retentive apparatus. 

In case the ulna is dislocated also, and is imprisoned by the annular 
ligament, circumduction with extension, as practised by Dr. Moore, and 
heretofore described, will be required. 

It only remains for us to determine the precise form of splint which 
ought to be preferred, and to describe its mode of application. 

The narrow "attelle cubitale" of Dupuytren is inconvenient: nor 
can I give the preference to the curved dorsal splint recommended by 
Xelaton, and employed by Robert Smith, Erichsen, and others. It is 
not to me a matter of entire indifference, in case only one curved splint 
is employed, whether this be applied to the palmar or dorsal surfaces of 
the forearm. Foreign surgeons, so far as I know, have applied this 
splint to the dorsal surface, and the straight splint to the palmar ; while 
American surgeons have adopted almost as uniformly the opposite rule — 
to whose practice, in this respect, I acknowledge myself also partial. It 
is to the curved splint rather than to the straight that we mainly trust ; 
not simply, or at all, perhaps, because of its form, but because the 
curved splint is also the long splint. This is the splint, therefore, which 
ought to be the most steady and immovable in its position. Now, the 



326 



FRACTURES OF THE RADIUS 



very irregularities of surface upon the palmar aspect of the forearm and 
hand, instead of constituting an embarrassment, enable us, when the 
splint is suitably prepared and adjusted, to fix it more securely. More- 
over, upon it alone, after a few days, the surgeon may see fit to rely, 
and in that case it ought to be applied to that surface of the arm which 
is most tolerant of continued pressure. The palmar surface, as being 
more muscular, and as having been more accustomed to friction and to 
pressure, must necessarily have the advantage in this respect. The 
palmar splint terminating also at the metacarpophalangeal articulations, 
instead of at the wrist, as the short straight splint must do when the 
hand is adducted, enables the hand to be flexed upon its extremity over 
a hand-block, or pad of proper size. Such are the not insignificant 
advantages which we claim for this mode over that pursued by our trans- 
atlantic brethren. 

The block, suggested first by Bond, of Philadelphia, is a valuable 
addition, since the flexed position is always more easy for the fingers, 
and in case of anchylosis this position renders the whole hand more 
useful. 

For myself, I am in the habit of preparing extemporaneously a splint 
from a wooden shingle, which I first cut into the requisite shape and 
length; the length being obtained by measuring from the front of the 
elbow-joint, when the arm is flexed to a right angle, to the metacarpo- 
phalangeal articulations, the fingers being first flexed. It ought, indeed, 
to fall half an inch short of the bend of the elbow, to render it certain 
that it shall make no uncomfortable pressure at this point; and the 
direction to measure with the arm flexed is of sufficient importance to 
warrant a repetition. The breadth of the splint should be in all its 
extent just equal to the breadth of the forearm in its widest part, except 
where it is to receive the ball of the thumb, so that there shall be no 
lateral pressure upon the bones. If the splint is of unequal breadth, 
the roller cannot be so neatly applied, and it is more likely to become 

disarranged. Thus constructed, it is to 
be covered with a sack of cotton cloth, 
made to fit moderately tight, with the 
seam along its back, and afterwards stuffed 
with cotton batting; or with curled hair. 
These materials may be pushed in, and 
easily adjusted, wherever they are most 
needed, from the open extremities of the 
sack. While preparing, the splint must 
be occasionally applied to the arm until 
it fits accurately every part of the fore- 
arm and hand, only that the stuffing must 
be more firm a little above the lower end 
of the upper fragment, and in the hollow 
of the hand. Between these two points there should be little or no 
cotton. The open ends of the sack are then to be neatly stitched over 
the ends of the splint, after which the splint may be laid directly upon 
the skin without any intermediate compresses or rollers. 

The advantages of this form of splint are easily comprehended. They 



Fig. 103. 




Author's palmar splint; right arm. 



Fig. 104. 



Author's dorsal splint; frequently 
omitted. 



COLLES S FRACTURE. 



327 



Fig. 101 



consist in facility and cheapness of construction, accuracy of adaptation, 
neatness, permanency, and fitness to the ends proposed. There is also 
no possibility of making painful or injurious pressure upon the arteries 
or nerves which lie upon the front of the wrist. 

The extemporaneous splint recommended by Dr. Isaac Hays, of 
Philadelphia, is very similar, but it lacks the neatness and permanency 
of that which I have now described. 

In most cases it is better to employ, also, at least during the first 
fortnight, a straight dorsal splint, of the same breadth as the palmar 
splint, and of sufficient length to extend from the elbow to the middle of 
the carpus. This should be covered and stuffed in the same manner as 
the palmar splint, except that here the thickest and firmest part of the 
splint must be opposite the carpus and the lower fragment. 

Having restored the fragment to place, in case of Colles's fracture, 
by some one of the methods already described, the arm is to be 
flexed upon the body, and placed in a position of semi-pronation ; when 
the splints are to be applied, and secured with a sufficient number 
of turns of the roller, taking espe- 
cial care not to include the thumb, 
the forcible confinement of which 
is always painful and never useful. 

Let me repeat that, in most 
cases, all of our success will de- 
pend upon whether we have pro- 
perly reduced the fracture in the 
early stage of the accident. When 
once reduced it is easily kept in 
place. 

I cannot too severely reprobate 
the practice of violent extension of 
the wrist in the efforts at reduc- 
tion, when no overlapping or im- 
paction of the fragments exists 
and the ulna is not dislocated ; and 
that, whether this extension be ap- 
plied in a straight line, or with the 
hand adducted. It has been shown 
that in a great majority of cases 
no indication in this direction is to 
be accomplished ; and to pull vio- 
lently, under these circumstances, 
upon the wrist, is not only useless, 
but hurtful. It is adding to the 
fracture, and to the other injuries 
already received, the graver pathological lesion of a stretching, a sprain 
of all the ligaments connected with the joint. I am persuaded that to 
this violence, added to the unequal and too firm pressure of the splints, 
are, in a great measure, to be attributed the subsequent inflammation 
and anchylosis in very many cases. 




The author's dressing complete. The curved 
palmar splint is not in view, only the dorsal. The 
faint white lines represent the roller. The sling 
is omitted, for the purpose of bringing the other 
dressings into view. 



328 FRACTURES OF THE RADIUS. 

The first application of the bandages ought to "be only moderately 
tight, and as the inflammation and swelling develop in these structures 
with rapidity the bandages should be attentively watched, and loosened 
as soon as they become painful. It must be constantly borne in mind 
that, to prevent and control inflammation, in this fracture, is the most 
difficult and by far the most important object to be accomplished, while 
to retain the fragments in place, when once reduced, is comparatively 
easy. 

During the first seven or ten days, therefore, these cases demand the 
most assiduous attention; and we had much better dispense with the 
splints entirely, as advised by Fauger and Pilcher, than to retain them 
at the risk of increasing the inflammatory action. Indeed, I have no 
doubt that very many cases would come to a successful termination 
without splints, if only the hand and arm were kept perfectly still in a 
suitable position until bony union was effected. 

I must also enter my protest against many or all of those carved 
splints which are manufactured, hawked about the country, and sold by 
mechanics, who are not surgeons ; with a fossa for each styloid process, 
a ridge to press between the bones, and various other curious provisions 
for supposed necessities, but which never find in any arm their exact 
counterparts, and only deceive the inexperienced surgeon into neglect of 
the proper means for making a suitable adaptation. They are the fruitful 
sources of excoriations, ulcerations, inflammations, and deformities. 

In reference to the treatment of these fractures, the following cases 
and the accompanying remarks, by that great surgeon, Dupuytren, are 
too pertinent not to merit a place in every treatise of this character. 

" The two succeeding cases are not only interesting as fractures of 
the radius, but they are farther deserving of attentive consideration, on 
account of the serious complications which accompanied them, and 
which were the consequence of forgetting an important precept. More 
than once, indeed, it has occurred that the surgeons have been so intent 
on preserving fractures in their proper position that the extreme con- 
striction employed has actually caused destruction of the soft parts. A 
piece of advice which I have very frequently given, and which I cannot 
too often repeat, is to avoid tightening too much the apparatus for frac- 
tures during the first few days of its being worn ; for the swelling which 
supervenes is always accompanied by considerable pain, and may be fol- 
lowed by gangrene. It cannot, therefore, be too urgently impressed on 
young practitioners, to pay attention to the complaints which patients 
make ; and to visit them twice daily, and relax the bandages and straps 
as need may be, in order to obviate the frightful consequences which 
may spring from not heeding this necessary precaution ; by carefully 
attending to this point I have been saved the painful alternative of 
ever having to sacrifice a limb for complications which its neglect may 
entail. 

"Antoine Rilard, set. 44, fractured his right radius whilst going down 
into a cellar, in Feb. 1828, and went at once to the Hospital of La 
Charite. When the fracture was reduced (it was near the base of the 
bone) an apparatus was applied, but fastened too tightly ; and, notwith- 
standing the great swelling and the acute pain which the patient en- 



FRACTURES OF THE RADIUS. 329 

clured, it was not removed until the fourth day, when the hand was 
cold and oedematous, and the forearm red, painful, and covered with 
vesications. Leeches, poultices, and fomentations were applied, and 
followed by some alleviation of the local symptoms, though there was 
much constitutional disturbance. At the close of a fortnight from the 
accident, the palmar surface of the forearm presented a point where 
fluctuation was supposed to exist ; but when a bistoury was plunged 
into it no matter followed. Portions of the flexor muscles subsequently 
sloughed, and the skin subsequently mortified. The only resource was 
amputation, which was performed above the elbow six weeks after his 
admission ; and he afterwards recovered without the occurrence of any 
further untoward symptoms. 

" R., set. 36, was at work boring an artesian well in 1832, when he 
was struck by part of the machinery on the right arm ; he was instantly 
knocked down and thrown violently on the right thigh. A surgeon who 
was sent for detected a fracture of the radius, and applied the usual 
apparatus, consisting of pads and splints, confined by a roller extending 
from the extremities of the fingers to the elbow, which compressed the 
arm so tightly as to give rise to very great suffering. The fingers, hand, 
and forearm were numbed almost to insensibility, and yet the surgeon 
in attendance did not think proper to loosen the apparatus. Such was 
the condition of the patient until he came to the Hotel Dieu, four days 
after the accident ; the fingers were then black, cold, and insensible, and 
when I removed the splints I found the hand likewise black, especially 
on its palmar surface. The lower part of the forearm was a shade less 
livid, but equally cold and insensible ; and several vesicles filled Avith 
pink-colored serum were apparent on both its surfaces where the splints 
had pressed ; the upper part of the forearm was inflamed, swollen, and 
very painful. He was bled and leeches were applied to the inflamed 
part of the arm ; camphorated spirit was applied to the fingers. 

" On the following day heat was restored as low as the wrist, but the 
hand remained for the most part livid and cold, and the radial artery 
did not pulsate. Seventy leeches were applied to the forearm, and the 
local application was continued." On the second day after admission 
thirty more leeches were applied. On the fourth clay the hand looked 
a little better, so as to " encourage some hope of its being saved ; but 
this was again blighted on the sixth day, by the entire loss of heat and 
sensibility in the part and increased pain and swelling in the forearm, to 
which the gangrene subsequently extended. On the twelfth day ampu- 
tation was performed at the elbow-joint ; but the patient did not survive 
the operation more than ten days, the immediate cause of death being 
acute pleurisy. There was a considerable quantity of purulent serosity 
on the right side of the chest ; and abscesses were found in the lungs 
and liver. On examining the arm, there was found to be a simple fracture 
of the radius about its centre. 

" The above case presents a painful illustration of the neglect to which 
I have alluded. In nearly every instance the swelling of the limb re- 
quires that careful attention should be paid to the bandage or straps, by 
which the apparatus is confined. Similar accidents are likely to result 
from the employment of an immovable apparatus, of which an example 
22 



330 FEACTUKES OF THE RADIUS. 

occurred in the practice of M. Thierry, one of my pupils. He was sum- 
moned to visit a young girl, on whom such an apparatus had been applied 
for supposed fracture of the radius. After suffering excruciating tor- 
ment, the forearm mortified, and amputation was the only resource ; on 
examining the limb no trace of fracture could be discovered. Had a sim- 
ple apparatus been here employed, and properly watched, the patient's 
limb would not 'have been sacrificed." 1 

Robert Smith mentions, also, the case of a boy, set. 18, who had a 
fracture of the lower extremity of the radius, through the line of the 
junction of the epiphysis with the diaphysis, caused by being thrown 
from a horse. A surgeon applied, within an hour, a narrow roller tightly 
around the wrist. On the following day the limb was intensely painful, 
cold and discolored ; still the roller was not removed, nor even slackened. 
On the fourth day he was admitted into the Richmond Hospital, when 
the gangrene had reached the forearm. Spontaneous separation of the 
soft parts finally occurred, and the bones were sawn through twenty-four 
days after the fracture was produced, from which time " everything pro- 
ceeded favorably." 2 

Nov. 21, 1851, a boy, ten years old, living in the town of Andover, 
Mass., had his left hand drawn into the picker of a woollen mill, pro- 
ducing several severe wounds of the hand and a fracture of the radius 
near its middle. One of the wounds was situated directly over the point 
of fracture, but whether it communicated with the bone or not was not 
ascertained. A surgeon was called, who closed the wounds, covered the 
forearm with a bandage from the hand to above the elbow, and applied 
compresses and splints. This lad made no complaint, his appetite re- 
maining good and his sleep continuing undisturbed, until the third day, 
when he began to speak of a pain in his shoulder ; on the same day also 
it was noticed that his hand was rather insensible to the prick of a pin. 
Early on the morning of the fourth day his surgeon, being summoned, 
found him suffering more pain and quite restless ; and on removing the 
dressings, the arm was discovered to be insensible and actually mortified 
from the shoulder downwards. 

Opiates and cordials were immediately given to sustain the patient, 
and fomentations ordered. 

On the sixth day a line of demarcation commenced across the shoulder, 
and on the twenty-first day the father himself removed the arm from the 
body by merely separating the dead tissues with a feather. Subse- 
quently a surgeon found the head of the humerus remaining in the 
socket, and removed it, the epiphysis having become separated from the 
diaphysis. The boy now rapidly got well. 

In the year 1853 this case became the subject of a legal investigation, 
in the course of which Dr. Pilsbury, of Lowell, Mass., declared that in 
his opinion this unfortunate result had been caused by too tight bandag- 
ing, and by neglecting to examine the arm during four days. 

On the other hand, Drs. Hayward, Bigelow, Townsend, and Ainsworth, 
of Boston, with Kimball, of Lowell, Drs. Loring and Pierce, of Salem, 

1 Dupuytren, Injuries and Diseases of Bones, Syd. ed., London, 1847, pp. 145-7. 

2 R. Smith, Treatise on Fractures, etc., Dublin, 1854, p. 170. 



FRACTURES OF THE RADIUS. 331 

believed that the death of the limb was due to some injury done to the 
artery near the shoulder-joint ; and in no other way could they explain 
the total absence of pain during the first two days : nor could they re- 
gard this condition as consistent with the supposition that the bandage 
occasioned the death of the limb. 1 

I cannot but think, however, that these gentlemen were mistaken, and 
that the gangrene was alone due to the bandages. In a similar case 
which came under my own observation, and in which both the radius and 
ulna were broken, the roller extended no higher than just above the 
elbow, and the patient complained of no pain until the bandages were 
unloosed, yet the arm separated at the shoulder-joint. I shall refer again 
to this example in the chapter on fractures of the radius and ulna ; and 
shall take occasion then also to speak more fully of the causes of these 
terrible accidents. 

Norris mentions another case of compound fracture of the lower end 
of the radius which came under his notice at the Pennsylvania Hospital 
in August, 1837, the arm having been dressed by a surgeon within half 
an hour after the accident, witli bandages and splints. When these band- 
ages were removed at the hospital, on the fifth day, " the soft parts 
around the fracture were found to have sloughed, an abscess extended 
up to the elbow-joint, and sloughs existed over the condyle. Severe con- 
stitutional symptoms arose, making amputation of the arm necessary.'* 2 

A lady, get. 50, was also seen by Thierry, who, having broken the 
radius near its lower end, lost her fingers by the sloughing consequent 
upon a tight bandage. 3 

A woman was admitted into one of Dr. Wood's wards in the Belle vue 
Hospital about the 1st of February, 1863, who had fallen upon her hand 
a few days before and broken the radius just above the wrist. Her arm 
was dressed with splints and bandages at one of the dispensaries in this 
city. Gangrene ensued, and when I saw her on the 8th of February, 
the death had extended to the middle of the forearm, the dead tissues 
being dry and black. Dr. Wood amputated the arm, but she died. 

The remarks which have now been made in relation to the treatment 
of Colles's fracture are applicable, with only such slight modifications 
as would naturally be suggested, to fractures of the lower end of the 
radius commencing upon the radial side of the bone and extending ob- 
liquely downwards into the joint ; and it is to this form of fracture espe- 
cially, that the pistol-shaped splint must be found applicable. If the 
fracture actually extends into the joint, it must not be forgotten that, in 
order to the prevention of anchylosis, the wrist should be early subjected 
to passive motion. 

The following example of a compound comminuted fracture of the 
radius may serve to illustrate the value of a somewhat novel mode of 
treatment under certain circumstances : — 

William Croak, of Buffalo, get. 30. January 29, 1856, a large piece 
of iron casting fell upon his arm, crushing and lacerating the wrist, and 

1 Bost. Med. and Surg. Journ., vol. xlviii. p. 281. 

2 Norris, note to Liston's Surgery, p. 54. 

3 Anier. Journ. Med. Sci., vol. xxv. p. 461, from L'Experience for 1838. 



332 



FRACTURES OF THE RADIUS 



Fig. 106. 



comminuting the lower part of the radius ; he was immediately taken to 
the Hospital of the Sisters of Charity. I found the whole of the soft 
parts torn away in front of the joint, and the fragments of the radius 
projected into the flesh in every direction. The hope of saving the hand 
seemed to be scarcely sufficient to warrant the attempt ; at least by the 
ordinary mode of procedure. I, however, stated to the gentlemen pre- 
sent, among whom were Dr. Rochester, my colleague, and the house sur- 
geon, Dr. Lemon, that I believed it could be saved if, having removed 
the fragments of the radius, we practised resection of the lower end of 
the ulna, and allowed the muscles to become completely relaxed. Ac- 
cordingly, after placing my patient under the influence of chloroform, I 
enlarged the wounds so as to enable me to remove six or seven fragments 
of the radius, leaving others which were broken off but not much dis- 
placed. I then removed with the saw one inch and a half of the lower 
end of the ulna. The hand was immediately drawn up by the contrac- 
tion of the remaining muscles, but their tension was completely relieved. 
The wounds were closed and dressed lightly, and the whole limb was 
placed on a broad and well- padded splint covered with oiled cloth. .The 
hand, which was very pale and exsanguine, was covered with 
warm cotton batting. 

The subsequent treatment was changed from time to time 
to suit the indications ; but his recovery was rapid and com- 
plete, nor was there at any time excessive inflammation in 
any part of the limb. 

1 have seen this man frequently since he left the hospital, 
and while he has recovered only a little motion in the wrist- 
joint, his hand and fingers are nearly as useful as before the 
accident. He is able to perform all ordinary kinds of labor 
with almost as much ease as most other men; and what is 
always gratifying to the humane surgeon, he does not fail to 
appreciate fully the service which has been conferred upon 
him by the preservation of his somewhat mutilated hand. 

I have recently adopted the same treatment with equal 
success in a case of gunshot wound of the lower end of the 
radius. 

Epiphyseal Separations. — This bone is formed from three 
centres, namely, one for the shaft and one for either ex- 
tremity. The shaft is ossified at birth. About the end of 
the second year ossification commences in the lower epiphy- 
sis, and it becomes united to the shaft at about the twentieth 
year. The same process commences in the upper epiphysis 
at about the fifth year, and is completed by consolidation 
with the shaft at the age of puberty. 

I have met with no recorded examples of separation of the 
upper epiphysis, and the examples of separation of the lower epiphysis 
have seldom been clearly made out. I have already mentioned one as 
having been reported by Robert Smith. He speaks also of other cases 
occurring in conjunction with a separation of the lower end of the ulna, 
and which, he thinks, are liable to be mistaken for dislocations. 1 



mm 

Radius with 

epiphyses. 

(From Gray.) 



Robert Smith, op. cit., p. 164. 



FRACTUEES OF THE ULNA. 333 

Malgaigne says that we have reasons to suspect this accident when the 
fracture occurs in persons under twenty years of age. Cloquet ascer- 
tained its existence by a dissection in a child of twelve years ; Roux also 
in a child whose age is not given, and Voillemier produced it easily in 
the dead bodies of children, and once in the body of a robust man of 
twenty-four. 1 I think I have broken the radius at the same point in 
some of my experiments of forced flexion in adult females, but I have 
not made the trial upon children. 

The treatment of this accident will not require any special considera- 
tion, since it will not differ essentially from the treatment required in a 
fracture occurring at the same point. 

Belayed or Non-union of Fractures of Ulna. — Muhlenberg in his 
tables has recorded 23 cases, of which 17 are reported as having been 
cured, and in 6 the attempts to cure have failed. Resection and drilling 
furnish the largest percentage of cures. 



CHAPTEE XXIII. 

FRACTURES OF THE ULNA. 

§ 1. Shaft of the Ulna. 

Causes. — The shaft of the ulna, when it alone is the seat of fracture, 
is generally broken by a direct blow. I have never seen an excep- 
tion to this rule ; but Voison related in the G-azette Medicate for 1833 
a single exception, in which it was said to have been broken by a fall 
upon the palm of the hand. Malgaigne thinks it is most often broken 
when one seeks to ward off a blow with the arm ; but it has happened 
most often to me to see it broken by a fall upon the side of the arm. 

Point of Fracture, Direction of Displacement, etc. — In an analysis of 
thirty-six cases, I find the shaft has been broken eleven times in its 
upper third, fourteen times in its middle third, and ten times in its loAver 
third. All portions seem, therefore, to be about equally liable to frac- 
ture. I think, also, the fractures have generally been oblique. 

Contrary to what has been observed by other writers, I have noticed 
that no law prevailed as to the direction in which the fragments have 
become displaced ; the broken ends being found directed forwards, back- 
wards, inwards, or outwards, according to the direction of the blow 
which has occasioned the fracture ; and this is in accordance with the 
general rule in other fractures occasioned by direct blows. No doubt, 
however, other things being equal, the tendency of the lower fragment 
would be toward the interosseous space, in consequence of the action of 
the pronator quadratus in this direction ; while the upper fragment, 
owing to its broad and firm articulation at the elbow-joint, can only be 
displaced forwards or backwards, at least to any great extent. 

1 Malgaigne, op. cit. 



331 



FRACTURES OF THE ULNA. 



Fig. 107. 



Complications. — In no case of the shaft of a long bone have I found 
serious complications more frequent than in fractures of the shaft of the 
ulna. Four have been compound ; twelve complicated with a forward, 
or forward and outward dislocation of the head of the radius ; one with 
a partial dislocation of the lower end . of the radius backwards ; and 
one with a dislocation of both radius and ulna backwards at the elbow- 
joint. It will be seen, therefore, that eighteen, or nearly 
one-half of the whole number, have been seriously com- 
plicated. 

Symptoms. — Occasionally this fracture is found to exist 
without sensible displacement. In such cases the diagnosis 
is sometimes difficult, and can only be determined by the 
crepitus and mobility. If, however, the ulna is firmly 
seized above and below the point which has suffered con- 
tusion, and pressed in opposite directions, these signs -will 
generally be sufficiently manifest, and will render the 
diagnosis certain. 

But in cases where there is considerable displacement, 
the inner margin of the bone is so superficial as to enable 
us to detect its deviations with the eje alone, or, when 
swelling has already occurred, by the fingers carried firmly 
and slowly along this margin. 

If the head of the radius is dislocated also, the displace- 
ment of the broken ends of the ulna must always be con- 
siderable, and the consequent deformity palpable. I have 
known one instance, however, in which a surgeon living in 
the neighboring province of Upper Canada recognized and 
reduced a dislocation of the radius and ulna backwards, 
but did not detect a fracture of the ulna two inches above 
its lower end. Six months after, in the month of March, 
1856, the patient called upon me with a marked deformity near the 
wrist, occasioned by the backward projection of the broken ulna, and 
w T ith a complete loss of the power of supination. It will not surprise us 
that this fracture was overlooked when we learn that the man had fallen 
fifty-five feet. 

Prognosis. — In simple fractures the prognosis is generally favorable, 
since no overlapping can occur, and the lateral displacements are not 
usually sufficient to produce a marked deformity, or to interfere mate- 
rially with the functions of the arm ; yet it is not unfrequent to find the 
fragments inclining slightly forwards or backwards, inwards or outwards. 
If the fragments fall toward the radius, I have noticed in three or four 
instances a slight projection of the lower end or styloid process of the 
ulna to the ulnar side ; but not interfering in any degree with the 
motions of the wrist-joint. 

I have seen the radius left unreduced nine times after a fracture of 
the ulna, and in each example the forearm was shortened. A boy, set. 
17, was struck by a locomotive, and severely injured in various parts of 
his body, June 5, 1855. I saw him, with two very intelligent country 
practitioners, a few hours after the accident. The whole left arm was 
then greatly swollen. Crepitus was distinct, and we easily recognized 






Fracture of the 
shaft of the ulna 



SHAFT OF THE ULNA. 335 

the fracture of the ulna about three inches below its upper end, with 
which an open wound was in direct communication. We suspected, also, 
a dislocation of the head of the radius forwards, but as we could not 
make ourselves certain, and finding that the arm was in such a condition 
as to preclude any further manipulation without greatly diminishing the 
chance of saving the limb, we made no attempt at reduction, but laid the 
arm upon a pillow and directed cool water lotions. 

At no subsequent period, in the opinion of the medical gentleman 
who was left in charge, did a favorable opportunity occur to reduce the 
radius ; and at the end of two months I found the ulna united, with the 
fragments bent forwards and outwards towards the radius, while the 
head of the radius lay in front of the humerus. The forearm was 
shortened three-quarters of an inch. He could flex his arm freely to a 
right angle and a little beyond ; and he could straighten it perfectly. 
Hand slightly pronated, with partial loss of supination. Whole arm 
nearly as strong and as useful as before the accident. 

The. second case occurred in the person of a man set. 26, residing 
about twenty miles from town, and was occasioned by the kick of a 
horse. This was also a compound fracture. It does not appear that 
his surgeon discovered the dislocation of the radius, but supposed that 
it was a fracture of both bones. On the ninth day the patient became 
dissatisfied and dismissed his surgeon, but employed no other. 

Oct. 1, 1849, eleven weeks after the accident, he called upon me. I 
found the ulna united, with a manifest displacement, but I could not 
discover that there had been any fracture of the radius. The head of 
the radius was in front of the external condyle, and a depression existed 
where it formerly articulated. When the arm was flexed, the head did 
not strike the humerus so as to arrest the flexion, but it glided upwards 
and outwards along the inclined base of the external condyle. He had 
already begun to use his arm considerably in labor. The forearm was 
shortened one inch. 

Three times I have noticed after the lapse of several years that the 
forearm could not be perfectly supinated ; but pronation was never 
permanently impaired. I think, also, that the motions of flexion and 
extension have always, except where the radius has remained dislocated, 
been completely restored soon after the splints were removed ; and 
even in these latter cases it is only extreme flexion which has been 
hindered. 

I have occasionally met with examples in which this bone has failed 
to unite, and Muhlenberg, in his tables, records sixteen cases. 

Treatment. — In simple fracture we must look carefully to the lateral 
deviation of the fragments ; and if they are found to be salient forwards 
or backwards, pressure made directly upon or near their extremities 
restores them to place, but it often requires considerable force to accom- 
plish this. A gentleman fell and broke the right ulna near its middle. 
He came immediately to me, and I found the fragments displaced back- 
wards. Pressing strongly with my fingers they sprung forwards with a 
distinct crepitus, and I thought they were now in exact line. A broad 
and well-padded splint was applied to the forearm, and I took especial 
pains with compresses nicely adjusted, from day to day, to keep every- 



336 FRACTURES OF THE ULNA. 

thing in place. The arm was placed in a sling. Eight months after 
the accident this gentleman died of cholera, and I was permitted to 
dissect the arm. I found the fragments well united, hut with a very 
palpable projection of the fragments backwards, in the direction in 
which they were at first. 

If the displacement is in the direction of the radius, it is more diffi- 
cult to overcome, but its necessity is much more urgent, since, if the 
fragments fall completely against the radius, a bony union may take 
place, occasioning a complete loss of the power of pronation and of 
supination. 

While moderate extension is being made, and the hand is well supi- 
nated, the fingers of the surgeon should be pressed firmly, and in spite 
sometimes of the complaints of the patient, between the radius and 
ulna, and the fragments of the broken ulna fairly pushed out from the 
radius. 

The forearm may now be laid in the usual position against the front 
of the chest, midway between supination and pronation, and the same 
splints applied and in the manner which we shall hereafter describe for 
fractures of the shaft of both bones. 

We ought, however, especially to bear in mind the danger of thrust- 
ing the fragments against the radius, by allowing the sling or the 
bandage to rest against the middle of the ulnar side of the bone. To 
prevent this the sling ought to support the arm by passing only under 
the hand and wrist, or the forearm may be laid in a firm gutter, which 
will touch the forearm only at the elbow and wrist, or it may be laid 
upon its back, as suggested and practised by Scott, and also by Fleury, 
the latter of whom, according to Malgaigne, had a case which had been 
treated in the position of semi-pronation, and which remained not only 
displaced, but refused to unite ; but when the arm was supinated the 
fragments came at once into contact, and bony union speedily took 
place. This position may be adopted whenever it is found to be prac- 
ticable ; but the position of semi-pronation is generally much more 
comfortable to the patient, at least when the forearm is laid across the 
chest, and I have found very few patients who would submit to a posi- 
tion of complete supination. 

In fractures accompanied with dislocation of the head of the radius 
forwards or backwards, nothing should prevent the immediate reduction 
of the dislocation but a demonstration of its impossibility, or a condition 
of the limb which would render manipulation hazardous. It can be 
reduced, generally, by pushing forcibly upon the head of the bone in 
the direction of the socket, while the arm is moderately flexed so as to 
relax the biceps, and while extension is being made at the forearm by 
an assistant. In making the counter-extension, care should be taken to 
seize the lower end of the humerus by the condyles, rather than by its 
anterior aspect, by which precaution we shall avoid pressing upon and 
rendering tense, the tendon of the biceps. 

July 29, 1845, a lad, get. 9, fell from his bed, breaking the ulna and 
dislocating the head of the radius. Dr. Austin Flint was called on the 
following morning, and at his request I was invited to see the patient 
with him. We found the ulna broken obliquely near its middle, and the 



CORONOID PROCESS OF THE ULNA. 337 

head of the radius dislocated forwards. While Dr. Flint sejzed the 
elbow in front of the condyles, I made extension from the hand, the 
forearm being slightly flexed upon the arm, and at the same moment I 
pushed forcibly the head of the radius back to its socket. The reduc- 
tion was accomplished easily and completely. 

We then dressed the arm with an angular splint, constructed with a 
joint opposite the elbow. This was laid upon the palmar surface, and 
the whole was nicely padded, especially in front of the head of the 
radius. In two weeks pasteboard was substituted for the angular splint. 
At the end of six weeks I was permitted to examine the arm, and found 
the head of the radius perfectly in place, but the points of fracture 
slightly salient. All of the motions of the arm were fully restored. 

June 2, 1845, C. C, aet. 9, fell upon his arm, breaking the ulna 
obliquely near its middle, and dislocating the head of the radius for- 
wards. Dr. J. P. White, being called, requested me to visit the patient 
with him. We found one of the broken fragments protruding through 
the skin, on the inside of the arm. 

With great ease, and by simply pressing with considerable force upon 
the head of the radius, it was made to slide into its socket. The case 
was left in charge of Dr. White. 

Five weeks after, I found all of the motions of the forearm completely 
restored, except that he could not extend it perfectly. The head of the 
radius was also a little more prominent in front than in the opposite 
arm. 

Four or five years later, the projection of the head of the radius had 
disappeared, and the functions of the arm were perfect. 

In Dr. Muhlenberg's tables of delayed and non-union, resection was 
practised three times, but with no recorded cures. This is a result 
which might reasonably be expected ; while drilling was practised six 
times, with five successes. 

§ 2. Coronoid Process of the Ulna. 

Dissections have established the possibility of this fracture as a simple 
accident in the living subject ; but I have not myself seen any example 
of which I can speak positively. In the two following cases, the exist- 
ence of such a fracture was at first suspected, but I have now very little 
doubt that my diagnosis was incorrect. I shall relate them, however, as 
examples of those accidents which are likely to be mistaken for fracture 
of this process. 

A laboring man, aged about twenty-five years, had been seen and 
treated by another surgeon, for what was supposed to be a simple dislo- 
cation of the radius and ulna backwards. The surgeon thought he had 
reduced the dislocation very soon after the accident. On the following 
day he found the dislocation reproduced, and he requested me to see the 
patient with him. The arm was then much swollen, but the character 
of the dislocation was apparent. By moderate extension, applied while 
the arm was slightly flexed, and continued for a few seconds, reduction 
was again effected, the bones returning to their places with a distinct 
sensation ; but on releasing the arm the dislocation w T as immediately re- 



338 FRACTURES OF THE ULNA. 

produced. These attempts to reduce and retain in place the dislocated 
bones were repeated several times during this day and on subsequent 
days, but to no purpose, and the patient was dismissed after about two 
weeks with the bones unreduced. 

The impossibility of retaining the bones in place, and the existence of 
an occasional crepitus during the manipulation, inclined me to believe 
at the time that the dislocation was accompanied with a fracture of the 
coronoid process. 

Another similar case has since presented itself in a child nine years 
old, and in which the subsequent examinations not only demonstrated the 
non-existence of a fracture, but also rendered doubtful the justness of 
the conclusions which I had drawn in the case just related. 

This lad fell, November 4, 1855, and his parents immediately brought 
him to me ; but as he lived many miles from town, I did not see him 
until eighteen hours after the injury was received. I found the arm 
much sw T ollen, slightly flexed, and pronated. Flexion and extension of 
the arm were very painful, the pain being referred chiefly to the front 
of the joint, near the situation of the coronoid process ; and at this point 
also there was a discoloration of the size of a twenty -five cent piece. 
Flexing the forearm moderately upon the arm and making extension, the 
bones came readily into place, but without sensation of any kind, either 
a snap or a crepitus. That the bones had now resumed their position, 
however, I made certain by a very careful examination with the hand 

Fig. 108. 




Fracture of the coronoid process. 

and by measurement, yet they would not remain in place one moment 
when the extension was discontinued. The reduction was made several 
times, and constantly with the same result. We then applied a right- 
angled splint to the arm, having first reduced the bones, and thus were 
able to retain them in position. I believed that the coronoid process 
w T as broken, and so informed the surgeon to whose care the boy returned. 

Five months after, he was brought again to me, and I then found that 
the radius and ulna had been kept in place ; the motions of the joint 
were perfect, and if the coronoid process had ever been broken it was 
now again in its natural position, and with every structure about it in a 
condition as complete as it was before the accident. For myself, I do 
not believe that so perfect a union of this process can happen ; at least 
in a case where, as must have been the fact in this example, the separa- 
tion and displacement of the process are such that it no longer offers an 
obstacle to the dislocation of the ulna backwards and upwards. 

Malgaigne thinks that the fracture is more frequent than the small 
number of reported examples w T ould lead us to suppose, especially be- 
cause he has noticed how often the summit of the process is broken off, 
when dislocation of the radius and ulna backwards is produced artificially 
on the dead subject. In three or four cases, also, of dislocations of 



CORONOID PROCESS OF THE ULNA. 339 

these bones backwards and inwards, which had come under his notice, 
he was unable to feel this process, and he therefore thought it probable 
that it was broken off. Other surgeons have thought, also, that it was 
a not infrequent accident ; and they have constantly made use of this 
supposition to explain those cases in which the radius and ulna, having 
been dislocated backwards, would not afterward remain in place when 
well reduced. Fergusson has indeed made the extraordinary statement 
in relation to dislocations of the radius and ulna backwards generally, 
that in these cases "the coronoid process will probably be broken." 

But, in my opinion, these fractures are exceedingly rare ; and I think 
these gentlemen need to have furnished some more conclusive evidence 
of the correctness of their opinions than can be found in their writings, 
or in the writings of any other surgeons which I have seen. 

Malgaigne mentions three reported examples, namely: one published 
by Combes Brassard, an Italian surgeon, in 1811, which Brassard saw 
only after a lapse of three months; one seen by Pennock, and published 
in the Lancet in 1828, the patient then being sixty years old, and the 
accident having occurred when he was a young man; the third was 
seen by Sir Astley Cooper, several months after the accident, and is 
reported by himself in his excellent treatise on Fractures and Disloca- 
tions. Says Sir Astley: "It was thought, at the consultation which 
was held about him in London, that the coronoid process was detached 
from the ulna." This was the only living example seen by Sir Astley 
in his long and immensely varied surgical practice; and even here we 
cannot fail to notice the apparent reserve with which he expresses his 
opinion — "It was thought at the consultation." 

To these examples our own researches have added a few others. 

Dorsey says that Dr. Physick once saw a fracture of the coronoid pro- 
cess. The symptoms resembled a luxation of the forearm backwards, 
" except that when the reduction was effected, the dislocation was re- 
peated, and by careful examination, crepitation was discovered. The 
forearm was kept flexed at a right angle with the humerus. The tend- 
ency of the brachialis internus to draw up the superior fragment was 
counteracted in some measure by the pressure of the roller above the 
elbow. A perfect cure was readily obtained." 1 In 1830, Dr. William 
M. Fahnestock reported a case occurring in a boy, who having fallen from 
a haymow, received the whole weight of his body " on the back part of 
the palm of the left hand," while the arm was extended forwards. It 
seemed to be a dislocation of the forearm backwards, but when reduced 
it was again immediately displaced, with an evident crepitus. The arm 
was secured in the angular splint of Dr. Physick and " recovered very 
speedily." 2 Dr. Couper, of the Glasgow Infirmary, also has reported a 
dislocation of the forearm backwards and outwards, occurring in a young 
man aged seventeen, and which he thinks was accompanied with this 
fracture. The dislocation was easily reduced, but returned again imme- 
diately on ceasing the extension. The fragment was not felt, nor does 
he speak of crepitus ; the existence of the fracture being inferred from 

1 Dorsey, Elements of Surgery, vol. i. p. 152. Philadelphia, 1813. 

2 Fahnestock, Anier. Journ. Med. Sci., vol. vi. p. 267. 



340 FRACTURES OF THE ULNA. 

the fact that the bones would not remain in place without help. The 
forearm was placed across the chest, with the fingers pointing toward the 
opposite shoulder, and secured in this position with splints and a band- 
age. At the end of four weeks union had taken place, with only slight 
deformity, although with some stiffness of the joint. 

In relation to this example, the editor remarks that the symptoms were 
not to his mind conclusive in determining the existence of a fracture of 
the coronoid process, and he inclines to the belief that it was rather an 
oblique fracture of the lower extremity of the humerus. " In cases like 
these," he adds, " where very rare accidents are suspected, we think 
that unless the diagnosis is clear, the leaning should always be the other 
way : we mean that, coeteris paribus, the symptoms should rather be 
referred to the common than the extraordinary injury. The contrary 
practice introduces a dangerous laxity in diagnosis." 1 

Dr. Duer, of Philadelphia, has reported a case which occurred in a 
boy six years old, and in which he felt and moved the fragment with his 
fingers. It was complicated with a dislocation, which remains unreduced. 
This case was last seen about seven weeks after the accident. 2 If at a 
later period we could be permitted to examine the patient, it is probable 
that the diagnosis might be rendered certain. 

In the American Medical Montldy for October, 1855, also, I find the 
report of a trial for malpractice, in which a lad nine years old received 
some injury about the elbow-joint which resulted in a maiming. The 
defendant claimed that there had been a dislocation of the forearm back- 
wards, accompanied either Avith a fracture of the trochlea of the hume- 
rus, or of the coronoid process of the ulna. 

Dr. Crosby, of Dartmouth College, testified that he had never met 
with a fracture of this process, yet he would not say that it did not exist 
in this case. He was not able to decide positively. Dr. Peaslee, of the 
same college, thought it altogether probable that it had been broken, and 
Dr. Spaulding was of the opinion fully that it had been broken. 

The jury did not agree, and a nonsuit was finally allowed by the 
court. 

The defendant, in his report of the trial, seems to me to have justly 
complained that Mr. Fergusson has said, that in a dislocation of the fore- 
arm backwards "the coronoid process will probably be broken." This 
was urged in the trial by the plaintiif's counsel as contradicting the med- 
ical testimony, and as evidence of a conspiracy on the part of the sur- 
geons to defeat the ends of justice ; since they constantly affirmed that 
the accident was so rare as not to have been reasonably expected, and 
that a failure to look for or to discover it did not imply a lack of ordi- 
nary skill or care. 3 

Mr. Allandale has reported another case accompanied with an old dis- 
location of the radius and ulna backwards, in which, having cut the tri- 
ceps and subsequently sawn off the olecranon process, he thus diagnosed 

1 Cooper, Med -Cliir. Rev., new ser., vol. xi. p. 509. 

2 Duer, Amer. Journ. Med. Sci., Oct. 1863, p. 390. 
» Op. cit., vol. lv. p. 339. 



CORONOID PROCESS OF THE ULNA. 



341 



109. 



a fracture of the coronoid process. He then proceeded to resect the joint, 
but omits to tell us precisely what he found when the fragments were 
removed. 1 

Says Mr. Liston : " The coronoid process is occasionally pulled or 
pushed off from the shaft, more especially in young subjects. I saw a 
case of it lately, in which the injury arose in consequence of the patient, 
a boy of eight years, having hung for a long time from the top of a wall 
by one hand, afraid to drop down ;" 2 after whom Miller, Erichsen, Skey, 
Lonsdale, and most of the Scotch and English surgeons have repeated 
the assertion that this process may be broken in this manner by the action 
of the brachialis anticus alone, yet no one of them has to this day seen 
another example. 

The explanation of the accident in the case of the boy, given by Lis- 
ton, implies two anatomical errors : first, that the coronoid process is an 
epiphysis during childhood ; and second, that the brachi- 
alis anticus is inserted upon its summit. The coronoid 
process is. never an epiphysis, but is formed from a com- 
mon point of ossification with the shaft ; the olecranon 
process and the lower extremity of the ulna having also 
separate points of ossification : the olecranon becoming 
united to the shaft at the sixteenth year, and the lower 
epiphysis at the twentieth. Moreover, the brachialis an- 
ticus has its insertion at the base of the process and partly 
upon the body of the ulna, but in no part upon its sum- 
mit ; indeed, the process seems rather to be intended as 
a pulley over which the brachialis anticus may play ; re- 
sembling also somewhat, in its function, the patella ; 
serving to protect the joint and perhaps the muscle itself 
from becoming compressed in the motions of the joint. 
Certainly it could never have been broken by the action 
of this muscle, and the case mentioned by Mr. Liston 
must find some other explanation. It may have been a 
rupture of the brachialis anticus itself, or of the biceps, 
or possibly a forward luxation of the head of the radius. 
Either of these suppositions is more rational than the 
statement made by Mr. Liston, because either one of them 
is possible, while his supposition is impossible. 

I have already quoted Dr. Hodges as saying that he 
had found the coronoid process broken off three times in 
connection with longitudinal fractures of the head of the 
radius. 

These, if I except my own, constitute all of the supposed examples 
seen in the living subject, of which I find any record ; twelve in all. 

It is true, however, that at least two other cases have been reported 
to me by letter, of which the writers speak with great confidence, and 
the authenticity of which I am unable to dispute ; but in neither case is 



Ulna, with epi- 
physis. (From 
Gray.) 



1 Allandale, Med. Times and Gazette, May 29, 1875. 

2 Liston, Practical Surgery, p. 55. 



342 FRACTURES OF THE ULNA. 

the testimony to me satisfactory, and as they are not upon record, I shall 
be excused from discussing their merits. 

The first two of the twelve above enumerated were not satisfactory to 
Malgaigne ; the third is spoken of cautiously by Sir Astley Cooper, as 
if it needed, in addition to his own great name, the indorsement of the 
" London council." Dorsey reports his case upon hearsay, and the 
result is quite too satisfactory to give it much claim to credibility. Fahne- 
stock's case is to our mind far from being fully proven. Couper's case 
is doubted by Dr. Johnson ; and the New Hampshire case was not made 
out satisfactorily to either the jury or the medical men. Liston's case 
was simply impossible. Duer's case could have been better verified at a 
later period. Having never seen a report of the three cases referred to 
by Dr. Hodges, I am unable to form any opinion as to their claims. 
His well-known reputation, however, disposes me to accept of them as 
authentic. 

Certainly it is not upon such testimony as this that we can rely to 
sustain Mr. Fergusson's opinion that this fracture is likely to occur in 
all dislocations of the forearm backwards, or of Malgaigne's conjecture 
that it is of more frequent occurrence than the published cases would 
seem to show. Nor will it be regarded as conclusive, that the beak of 
the process is often found broken after luxations made upon the sub- 
ject ; since between luxations thus produced and luxations occurring in 
the living subject there exists this important difference, that in the case 
of the latter, muscular action is the principal agent in the production of 
the dislocation, while in the former it is the external force alone which 
drives the bone from its socket. 

The fact, therefore, that so few cases have ever been reported, and 
that most of these are far from having been clearly made out, remains 
presumptive evidence that the actual cases are exceedingly rare ; but if 
to this we add such negative evidence as is furnished by actual dissec- 
tions, and by examinations of the pathological cabinets of the world, 
we think the testimony is almost conclusive. 

Only four specimens have been mentioned by any of the surgical 
writers known to me. Sir Astley Cooper says that a person was 
brought to the dissecting-room at St. Thomas's Hospital, who had been 
the subject of this accident. " The coronoid process, which had been 
broken off within the joint, had united by a ligament only, so as to move 
readily upon the ulna, and thus alter the sigmoid cavity of the ulna so 
much as to allow in extension that bone to glide backwards upon the 
condyles of the humerus." 1 Mr. Bransby Cooper adds in a note that 
the external condyle of the humerus was also broken and united by 
ligament. 

Samuel Cooper describes, rather obscurely, a specimen contained in 
the University College Museum, " in which the ulna is broken at the 
elbow, the posterior fragment being displaced backwards by the action 
of the triceps; the coronoid process is broken off; the upper head of 
the radius is also dislocated from the lesser sigmoid cavity of the ulna, 

1 Sir A. Cooper, Dislocations and Fractures, p. 411. 



CORONOID PROCESS OF THE ULNA. 343 

and drawn upwards by the action of the biceps. In this complicated 
accident, the ulna is broken in two places." 

Malgaigne says that Velpeau has also established by an autopsy the 
existence of a fracture of the coronoid apophysis, but without having 
given any further particulars in relation to the case. 

In addition to these examples, Dr. Charles Gibson, of Richmond, Va., 
has stated to me, by letter, that he has in his possession a specimen of 
this fracture, evidently belonging to an adult. The process was broken 
transversely near its extremity, and has united again quite closely and 
without any displacement, and without ensheathing callus. 

We must subject these specimens to analysis also. The first two 
were complicated with other fractures, and the second, especially, seems 
to have been a general crushing of all the bones concerned in the forma- 
tion of the elbow-joint ; neither of them could have been occasioned by 
contractions of the brachialis anticus, while only that one described by 
Sir Astley Cooper could have been the result of a dislocation of the 
forearm backwards. Of the specimen said to have been seen by Vel- 
peau, I am unable to speak without more circumstantial knowledge of 
its condition. Nor can I speak very confidently of that belonging to 
my distinguished friend, Dr. Gibson, of Virginia. Notwithstanding the 
respect which I entertain for his opinion, I cannot avoid a suspicion that 
the bone was never broken at all, since I find it more easy to believe 
that he is deceived by certain appearances, than that it should have 
united by bone again, and so perfectly as not to leave any line of sepa- 
ration or degree of displacement. Certainly the fracture was too high 
to have been produced by the action of the muscle, if such a thing were 
ever possible ; and if broken by a dislocation, which must have forced 
it violently from its position, as the ulna was driven upwards, it is to me 
incredible that it should ever be made to unite again so perfectly. 

We are therefore left as before, with no evidence that the coronoid 
process was ever broken by the action of a muscle, and with only one 
example in which it is probable that a fracture occurred as a conse- 
quence of a dislocation of the radius and ulna backwards. If then it 
does happen that in this dislocation it is pretty often found difficult or 
impossible to retain the bones in place without aid, it will be the part of 
prudence to ascribe this troublesome circumstance to some more common 
accident than a fracture of the coronoid process ; perhaps to a fracture 
of some portion of the lower end of the humerus, or to a disruption, 
more or less complete, of the tendons of the biceps and brachialis anticus, 
together with the ligaments which surround the joint. 

(Since writing the above my attention has been called to a review by 
Zeis of a paper on fractures of this apophysis, published by Lotzbeck, 
of Munich, in 1865. l The original paper furnishes five cases, to which 
the reviewer has added four more, one of which, Pennock's case, I have 
already spoken of. After a careful reading of the review, I fail to find 
conclusive evidence that the coronoid process was broken in either case. 
The evidence may be, indeed, in some of the cases probable, but never 

i Schmidt's Jahrbucli for 1866, vol. cxxxix. p. 134, et seq. 



344 FRACTURES OF THE ULNA. 

conclusive, since other explanations of the phenomena presented than 
those which are here offered would prove to me equally satisfactory.) 

Causes. — It is probable that this process will be sometimes broken in 
a fall upon the palm of the hand ; the force of the blow being received 
directly upon the lower end of the radius, and, through its numerous 
muscles and ligamentous attachments, being indirectly conveyed to the 
ulna, producing a violent concussion of the coronoid process against the 
trochlea of the humerus, and resulting finally in a fracture of this pro- 
cess and a dislocation of both bones of the forearm backwards. The 
gentleman seen by Sir Astley had fallen upon his extended hand while 
in the act of running. Brassard's patient had fallen also upon his hand 
with his arm extended in front. Pennock's patient, an old man of sixty 
years, had fallen upon the palm of his hand, and Fahnestock's fell upon 
the " back of the palm." In no other case is the point upon which the 
blow was received particularly mentioned. In two of the examples 
mentioned by Malgaigne there was a luxation of the forearm backwards ; 
such was also the fact in the case seen by Fahnestock ; in Couper's case 
it was dislocated backwards and outwards, and in Sir Astley's case I 
infer that there was only a subluxation of the ulna backwards. 

We know of no other causes, therefore, than such as equally tend to 
produce dislocations at the elbow-joint, unless we except direct crushing 
blows, which of course may break the bones at any point upon which 
the force happens to be applied. 

Symptoms. — Partial or complete displacement of the ulna, or of the 
radius and ulna backwards, accompanied with the usual signs of these 
luxations ; to which may be possibly added crepitus ; and it is fair to 
presume that in some examples the fragment, carried forwards by being 
driven against the trochlea, may be felt displaced and movable in the 
bend of the elbow. Brassard affirms that it was so with the patient 
whom he saw. If only the summit is broken off, the brachial anticus 
could have no influence upon it ; but if it were broken fairly through 
the base, it might be displaced slightly in the direction of the action of 
this muscle. 

The symptoms, however, which have been regarded as most diag- 
nostic, are the disposition to re-luxation manifested in most of these 
examples when the extension has been discontinued ; and especially the 
fact that the olecranon was particularly prominent when the arm was 
flexed to a right angle. But I am unable to understand how either of 
these circumstances can be better explained upon the supposition of a 
fracture of this apophysis, than without such a supposition. If the re- 
duction of both bones is once effected, even though the support of the 
coronoid process is completely lost, the head of the radius ought to 
prevent a re-luxation unless the arm is disturbed again ; nor can I un- 
derstand why, when the elbow is bent, the re-luxation is less likely to 
occur ; since, although in this position the humerus bears less directly 
upon the process, the difference in this respect must be very little, for 
in whatever position the arm is placed, so long as the radius retains its 
position the ulna cannot be drawn very forcibly against the humerus ; 
while, on the other hand, by flexing the arm the power of the biceps 
and of such fibres of the brachialis as remain attached to the ulna, to 



CORONOTD PROCESS OF THE ULNA. o4o 

aid in the maintenance of reduction, is completely lost ; and at the same 
moment the resistance, and consequent power of the triceps to produce 
the luxation, are greatly increased. 

In short, we must confess that we are here, also, notwithstanding 
the confidence with which writers have spoken of the signs of this acci- 
dent, very much in doubt ; nor do we see how these doubts can be re- 
moved until we have in detail the symptoms of at least one example, 
the indubitable existence of which has been subsequently verified by 
dissection. 

Prognosis. — In the case of Cooper's patient, seen several months 
after the accident, the ulna projected backwards while the arm was ex- 
tended, but it was without much difficulty drawn forwards and bent, 
and then the deformity disappeared. He thought that during exten- 
sion the ulna slipped back behind the inner condyle of the humerus. 
Brassard's patient, seen after three months, retained the power of 
pronation and supination, with also extension, but flexion was impos- 
sible, the forearm being arrested in this direction by the small, slightly 
movable fragment of bone in front of the elbow-joint, and which was 
supposed to be the process itself. Pennock's old man, who had met with 
the accident in boyhood, had still the radius luxated forwards and out- 
wards, and the olecranon more salient backwards than in the sound arm. 
Extension and flexion were nearly but not quite complete. Fahnestock 
informs us that his patient "recovered completely," but whether without 
deformity or maiming we are not told. Couper says the bone was 
united in four weeks, and that only a slight deformity and a little stiff- 
ness remained. Physick's patient made a perfect recovery. 

Let us come again to the dissection. Rejecting the doubtful speci- 
men belonging to Dr. Gibson, we have an exact account of only two, 
and, indeed, Sir Astley Cooper alone has described the mode of union. 
Samuel Cooper says that in the case of the University College specimen 
the radius is dislocated forwards and upwards, and the olecranon is dis- 
placed backwards, but he does not say whether the coronoid process has 
united, nor describe its position ; but Sir Astley informs us that in the 
example seen and dissected by him the process was united by ligament, 
which was sufficiently long and flexible to allow the fragment to move 
upwards and downwards in the motions of flexion and extension. 

In the absence of any other testimony, we may be allowed to express 
an opinion that when the fracture has taken place across the summit or 
above the insertion of the brachialis anticus, nothing but a ligam3ntous 
union can be regarded as possible, since the fragment can only derive 
nourishment from a few untorn fibres of the capsule and perhaps of the 
internal lateral ligaments ; and although it may not be displaced, it cannot 
have the advantage of impaction, upon which alone, I suspect, a fracture 
of the neck of the femur within the capsule must rely for a bony union, if 
it ever does so unite. If, however, the fracture has taken place at the 
base, and fortunately it has not become much displaced by the force of 
the concussion against the humerus, it does not seem to me so impossible 
that under favorable circumstances a bony union might now and then 
occur. It will be remembered that a good portion of the attachment of 
the brachialis anticus is still below r the fracture, and the remaining fibres 
23 



346 FKACTURES OF THE ULNA. 

are not therefore very likely to displace the fragment, especially when 
the arm is sufficiently flexed, so as to properly relax this muscle. 

It will be of small importance, however, whether the union is bony or 
ligamentous, provided only there is not great displacement. 

Treatment. — Whatever view we take of the pathology of this accident, 
the rational mode of treatment would seem to consist in flexing the arm 
at a right angle, and retaining it a sufficient length of time in that posi- 
tion ; not forgetting, however, the danger of anchylosis from long-con- 
tinued confinement in one position. 

An angular splint may be useful in preventing motion at first, but I 
think it ought not to be continued beyond seven or ten days at the most. 
After this, a simple sling is all that is necessary, since from this period 
some motion must be given to the joint if we would take the proper pre- 
cautions to prevent stiffness. Sir Astley Cooper thought the limb ought 
to be kept immovable three weeks, and Velpeau preferred four ; but I 
cannot agree with them, believing that the question of the future mobility 
of the elbow-joint is vastly more important than the question of a bony 
or ligamentous union between the fragments. Couper says that he 
adopted in the treatment of the case reported by him, extreme flexion ; 
but both Physick and Fahnestock placed the arm at right angles, and 
Sir Astley Cooper has recommended the same position. The latter posi- 
tion has always the advantage in case permanent anchylosis occurs, and 
the former cannot add much to the chance of complete replacement of 
the fragment. 

Bandages are only serviceable to retain the splint in place, and they 
may be thrown aside as soon as the splint is removed. 

§ 3. Fractures of the Olecranon Process. 

Causes.- — My records furnish me with accounts of only seventeen of 
these fractures, and, so far as I have been able to ascertain, all were 
occasioned by falls upon the elbow, or by blows inflicted directly upon 
the part. Malgaigne has, however, been able to collect accounts of six 
examples of fracture of the olecranon, produced, as is affirmed, by the 
violent action of the triceps ; as in pushing with the arm slightly flexed, 
in throwing a ball, in plunging into the water with the arms extended, 
etc.; but only four of these reported examples does he think are suffi- 
ciently authenticated to entitle them to be received as facts ; nor do I 
think it possible to affirm positively that in any instance, where the whole 
process is broken off, the triceps alone has occasioned the separation. 
For example, Capiomont reports the case of a cavalier, who, being in- 
toxicated, was thrown head foremost from his horse, and, striking probably 
upon his head, was found to have broken the olecranon process. We do 
not, in this example, see evidence alone of a forcible contraction of the 
triceps, but also of violent pressure against the hand and in the direction 
of the axis of the forearm toward the elbow-joint, by which the olecra- 
non process might have been so thrown forwards against the fossa of the 
humerus as to cause its separation. The same explanation might apply 
to several of the other examples. 



FRACTURES OF THE OLECRANON PROCESS. 347 

Point and Direction of Fracture ; Displacement, etc. — The process 
may be broken at its summit, at its base, or intermediate between these 
two extremes, the last of which is the most common. 

It is probable that when the action of the triceps alone has produced 
the fracture, it will be found that only that portion which receives the 
insertion of the triceps has been broken off. Malgaigne, who has been 
able to find upon record only two cases of a fracture of the extreme 
end of the process, declares that they were both occasioned by muscular 
action. 

Fractures of the middle are generally transverse, or only slightly 
oblique, occurring in the line of the junction of the epiphysis with the 
diaphysis. 

Fractures through the base are generally quite oblique, the line of 
fracture extending from before downwards and backwards, so that not 
only the whole of the process, but a portion of the back of the shaft is 
carried away ; and this accident can scarcely happen, except by a blow 
received upon the lower end of the humerus, directly in front of the 
process ; or, what w T ould amount to the same thing, by a blow from be- 
hind, received upon the ulna just below the olecranon process, or by 
wrenching the forearm violently back, while the humerus is fixed. 

The only displacement to which the upper fragment seems to be liable, 
is in the direction of the triceps ; and the degree of this displacement 
does not depend so much upon the 

point at which the fracture has taken Fig. HO- 

place as upon the violence which has 
occasioned it, the extent of the dis< 
ruption of the ligaments, aponeurosis 
of the triceps and of the capsule, and 
upon whether, since the accident, 
the arm has been flexed or kept ex- 
tended. 

In four instances I have found dis- 
tinct crepitus immediately after the 
fracture has occurred, produced by 
only moving the fragment laterally, 

showing plainly that little or no displacement had taken place. The fol- 
lowing example will show also that this displacement does not always 
happen even after the lapse of several clays, and where no surgical treat- 
ment has been adopted. 

Samuel Duckett, set. 14, fell upon the point of the elbow, and two 
days after was admitted to the Buffalo Hospital of the Sisters of Charity. 
The elbow was then much swollen, but no crepitus could be detected, 
and he could nearly straighten his arm by the action of the triceps. On 
the sixth day, the swelling having sufficiently subsided, a distinct crepi- 
tus was discovered when the olecranon process was seized between the 
fingers and moved laterally. We extended the arm immediately, and 
applied a long gutta-percha splint to the whole front of the arm and fore- 
arm, securing it in place with a roller. On the eleventh day, five days 
after the first dressing, the splint was taken off and its angle at the 
elbow-joint slightly changed ; and this was repeated every day until the 




348 FRACTURES OF THE ULNA. 

twenty-second from the time of the accident. The splint was then finally 
removed, when the fragment was found to be united without any per- 
ceptible displacement, and the motions of the joint were unimpaired. 

It must not be inferred, however, that it is always prudent to leave 
this fracture thus unsupported, since it has occasionally happened that 
the displacement, which did not exist at first, has taken place to the 
extent of half an inch or more, after the lapse of several days. Mr. 
Earle mentions a case in which the separation did not take place until 
the sixth day, when it was occasioned by the patient's attempting to tie 
his neckcloth. 

Symptoms. — The usual signs of a fracture of the olecranon process 
are, when the fragments are not separated, crepitus, discovered especi- 
ally by seizing the process and moving it laterally ; or, when displace- 
ment has actually taken place, the crepitus may be discovered sometimes 
by extending the forearm, and pressing the upper fragment downwards 
until it is made to touch the lower fragment ; the existence of a palpable 
depression between the fragments, partial flexion of the forearm, and 
inability on the part of the patient to straighten it completely, or even 
to flex the arm in some cases. If the fragments do not separate, gentle 
flexion and extension of the arm, while the finger rests upon the process, 
may enable us to detect the fracture. 

It will sometimes happen that, OAving to the rapid occurrence of tume- 
faction, the evidence of a fracture will be quite equivocal ; but, in all 
cases where a severe injury has been inflicted upon the point of the 
elbow, it will be well to suspend judgment until, by repeated examina- 
tions, made on successive days, the question is determined. Meanwhile, 
the arm ought to be kept constantly in an extended position, as if a frac- 
ture was known to exist. 

Prognosis.- — In a large majority of cases this process becomes re- 
united to the shaft by ligament, which may vary in length from a line 
to an inch or more, and which is more or less perfect in different cases. 
Sometimes it is composed of two separate bands, with an intermediate 
space, or the ligament may have several holes in it ; at other times it is 
composed in part of bone and in part of fibrous tissue ; but most fre- 
quently it is a single, firm, fibrous cord, whose breadth and thickness are 
less than that of the process to which it is attached. 

If the fragments are maintained in perfect apposition, a bony union 
may occur, yet it is not invariably found to have taken place, even under 
these circumstances. Malgaigne thinks also, he has seen one case in 
which there was neither bone nor fibrous tissue deposited between the 
fragments. This was an ancient fracture at the base of the olecranon ; 
the superior fragment remained immovable during the flexion and exten- 
sion of the arm, yet it could be moved easily from side to side. 

In my own cases I have five times found the fragments united with- 
out any appreciable separation, and have presumed that the union was 
bony. One of these examples I have already mentioned ; the second 
was in the person of a lady, aged about forty years, who, having fallen 
down a flight of steps on the 8th of September, 1857, sent for me imme- 
diately. I found a large bloody tumor covering the elbow-joint, but 
there was no difficulty in detecting a fracture of the olecranon process. 



FRACTURES OF THE OLECRANON PROCESS 



349 



Fig. 111. 



It was easily moved from side to side, and this motion was accompanied 
with a distinct crepitus. During the first week the arm was only laid 
upon a pillow, but as it was found to become gradually more flexed, and 
the swelling having in a great measure subsided, the arm was nearly, 
but not quite, straightened, and a long gutta-percha splint applied to the 
palmar surface of the forearm and arm. The fragments united in about 
twenty or twenty-five days, and without separation, so far as could be 
discovered in a very careful examination. 

The third example to which I have referred, occurred in a boy four- 
teen years old, and was treated by Dr. Benjamin Smith, of Berkshire, 
Massachusetts. Sixty-nine years after, he being then eighty-three years 
old, I found the olecranon process united apparently by bone, but to that 
day he had been unable to straighten the arm completely, or to supine it 
freely. 

In one instance I found the fragment, after the lapse of one year, 
united by a ligament, which seemed to be about one-quarter of an inch 
in length, and the arm appeared to be in all respects as 
perfect as the other. He could flex and extend it freely. 

In the two following examples, also, the bond of union 
was ligamentous: — 

John Carbony, ret. 18, having broken the olecranon, it 
was treated with a straight splint. Nine years after, I 
found the process united by a ligament half an inch in 
length, and he could nearly, but not entirely, straighten 
the arm. In all other respects the functions and motions 
of the arm were perfect. 

A lad, set. 15, was brought to me by Dr. Lauderdale, 
a very excellent surgeon in the town of Geneseo, Living- 
ston Co., N. Y., whose olecranon process had been 
broken by a fall six months before, and at the same time 
the head of the radius had been dislocated forwards. I 
found the radius in place, and the olecranon process 
united by a ligament about half an inch in length. He 
was not able to straighten the arm completely, the fore- TT . . . 

. . ~ r n . \ J Union by ligament. 

arm remaining at an angle ot 45 with the arm. 

Treatment. — It will surprise the student who is yet unacquainted with 
the literature of our science, to learn that in relation to the treatment of 
a fracture of the olecranon process, a wide difference of opinion has been 
entertained as to what ought to be the position of the arm and the fore- 
arm, in order to the accomplishment of the most favorable results ; and 
that, while some insist upon the straight position as essential to success, 
others prefer a slightly flexed position, and still others have advocated 
the right-angled position. Thus Hippocrates, and nearly all of the ear- 
lier surgeons, down to a period so late as the latter part of the last cen- 
tury, directed that the arm should be placed in a position of semiflexion; 
Boyer, Desault, and, after them, most of the French surgeons of our 
own day, prefer a position in which the forearm is very slightly bent 
upon the arm ; while Sir Astley Cooper, and a large majority of the 
English and American surgeons, employ complete or extreme extension. 




350 FRACTUEES OF THE ULNA. 

The arguments presented by the advocates and antagonists of these 
various plans deserve a moment's consideration. 

In favor of the position of semiflexion, requiring no splints, and, in the 
opinion of some writers, not even a bandage, but only a sling to support 
the forearm, it is claimed that it leaves the patient at liberty at once to 
walk about and to move the elbow-joint freely, so soon at least as the 
subsidence of the swelling and pain will permit, and that in this way the 
danger of anchylosis is greatly diminished ; that, moreover, if anchylosis 
should unfortunately occur, the limb is in a much better position for the 
proper performance of its most ordinary functions than if it were ex- 
tended. Some have also added to this argument a statement that a 
fibrous union, under any circumstances, is inevitable, and that it is a 
matter of little consequence whether the ligament thus formed is long or 
short, since in either condition it will be equally serviceable. 

In reply to these statements, it may be said briefly that they are nearly 
all based upon false premises, or that they have been proven in them- 
selves to be essentially erroneous. 

Anchylosis is always a serious event, Avhich by all possible means the 
surgeon will seek to prevent, but position has nothing to do with deter- 
mining this result ; when it does occur, it may usually be ascribed either 
to the severity and complications of the original injury, to the violence 
of the consequent inflammation, or to having neglected, at a proper 
period and with sufficient perseverance, to move the joint. 

That a fibrous union is inevitable under any circumstances, has been 
proven to be an error ; and while a short ligamentous union, such as is 
usually obtained when the arm is kept straight, may serve its purposes 
quite as well as a bony union, yet a long fibrous union, such as must 
very often be obtained when the arm is kept at a right angle, would 
seriously impair the usefulness of the limb. 

The only argument which remains, and which really possesses any 
weight, is, that, if permanent anchylosis does actually occur, the arm, 
when semiflexed, is in a better position for the performance of its ordi- 
nary functions ; and this, considered as an argument in favor of the uni- 
versal or even general adoption of the flexed position, is successfully met 
by a statement of the infrequency of permanent anchylosis after a simple 
fracture, when the case has been properly treated, whether by the flexed 
or straight position ; while, if the limb is flexed, a maiming, as a result 
of the great length of the intermediate ligament, is quite as likely to 
occur. 

Yet if, in any case, from the great severity and complications of the 
injury, especially in certain examples of compound and comminuted 
fracture, it were to be reasonably anticipated that permanent bony an- 
chylosis must result, or even where the probabilities were strongly that 
way, the surgeon might be justified in selecting for the limb, at once, 
the position of semiflexion ; or he might leave the arm without a splint, 
and at liberty to draw up spontaneously and gradually to this position, 
as it is always very prone to do. 

In favor of moderate, but not complete extension, it is claimed that it 
is less fatiguing than the latter position, while it accomplishes a more 



FRACTURES OF THE OLECRANON PROCESS. 351 

exact apposition of the fragments, if they happen to be brought actually 
into contact. 

I am unable, however, to understand how the apposition can be ren- 
dered less exact by complete extension, unless by this is meant a degree 
of extension beyond that which is natural, and which, I am well aware, 
is permitted to the elbow-joint when this posterior brace is broken off. 
It would certainly derange the fragments to place the arm in this ex- 
treme condition of extension — that is, in a condition of extension ap- 
proaching dorsal flexion, which is beyond what is natural. Indeed, 
perhaps we may admit that, in order to perfect apposition, the extension 
ought to be less by one or two degrees than what is natural, sufficient to 
compensate for the trifling amount of effusion which may be presumed 
to have occurred in the olecranon fossa, and which would prevent the 
process from sinking again fairly into its fossa. 

As to its being less fatiguing, it is well known to those accustomed to 
treat fractures of the thigh by permanent extension that the muscles 
rapidly acquire a tolerance, which soon dissipates all feeling of fatigue, 
and that, after a few hours, or days at most, the patients express them- 
selves as being more comfortable in this position than in the flexed. 

Finally, the advocates of complete, natural extension claim that in 
this position alone is the triceps most perfectly relaxed, and conse- 
quently the most important indication, namely, the descent of the olecra- 
non, most fully accomplished. In this opinion we also concur ; and 
regarding all other considerations, in the early days of the treatment, 
as secondary to this one, we unhesitatingly declare our preference for 
what has been called the " position of complete extension," as opposed 
to flexion, semiflexion, or extreme extension. 

It only remains for us to determine by what means the limb can be 
best maintained in the extended position, and the olecranon process most 
easily and effectually secured in place. 

For this purpose a variety of ingenious plans have been devised, such 
as the compress and "figure-of-8" bandage of Duverney, without splints; 

Fig. 112. 




Sir Astley Cooper's method 



or a similar bandage employed by Desault, with the addition of a long- 
splint in front; the circular and transverse bandages of Sir Astley 
Cooper, with lateral tapes to draw them together, to which also a splint 
was added; and many other modes not varying essentially from those 
already described, but nearly all of which are liable to one serious ob- 
jection, namely, that if they are applied with sufficient firmness to hold 
upon the fragment, and Boyer says they " ought to be drawn very 
tight," they ligate the limb so completely as to interrupt its circulation, 
and expose the limb greatly to the hazards of swelling, ulceration, and 



352 FRACTUKES OF THE ULNA. 

even gangrene. How else is it possible to make the bandage effective 
upon a small fragment of bone, scarcely larger than the tendon which 
envelops its upper end, and with no salient points against which the 
compress or the roller can make advantageous pressure ? If, then, these 
accidents — swelling, ulceration, and gangrene— are not of frequent oc- 
currence, it is only because the bandage has not been generally applied 
a very tight," and while it has done no harm, it has as plainly done no 
good. 

The dangers to which I allude may be easily avoided, without relax- 
ing the security afforded by the compress and bandage, by a method 
which is very simple, and the value of which I have already sufficiently 
determined by my own practice. 

The surgeon will prepare, extemporaneously always, for no single 
pattern will fit two arms, a splint, from a piece of thin, light board. 
This must be long enough to reach from near the wrist-joint to within 
three or four inches of the shoulder, and of a width nearly or quite equal 
to the widest part of the limb. Its width must be uniform throughout, 
except that, at a point corresponding to a point three inches, or there- 
abouts, below the top of the olecranon process, there shall be a notch 
on each side, or a slight narrowing of the splint. One surface of the 

Fig. 113. 




The author's method when the fragments are widely separated. 

splint is now to be thickly padded with hair or cotton-batting, so as to 
fit all of the inequalities of the arm, forearm, and elbow, and the whole 
covered neatly with a piece of cotton cloth, stitched together upon the 
back of the splint. Thus prepared, it is to be laid upon the palmar sur- 
face of the limb, and a roller is to be applied, commencing at the hand 
and covering the splint, by successive circular turns, until the notch is 
reached, from which point the roller is to pass upwards and backwards 
behind the olecranon process and down again to the same point on the 
opposite side of the splint; after making a second oblique turn above the 
olecranon, to render it more secure, the roller may begin gradually to 
descend, each turn being less oblique, and passing through the same 
notch, until the whole of the back of the elbow-joint is covered. This 
completes the adjustment of the fragments, and it only remains to carry 
the roller again upwards, by circular turns, until the whole arm is 
covered as high as the top of the splint. 



FRACTURES OF THE OLECRANON PROCESS. 353 

The advantage of this mode of dressing must be apparent. It leaves, 
on each side of the splint, a space upon which neither the splint nor 
bandage can make pressure, and the circulation of the limb is, therefore, 
unembarrassed, while it is equally effective in retaining the olecranon in 
place, and much less liable to become disarranged. 

Before the bandage is applied about the elbow-joint, the olecranon 
must be drawn down, as well as it can be, by pressure with the fingers, 
and a compress of folded linen, wetted to prevent its sliding, must be 
placed partly above and partly upon the process; at the same time, 
also, care must be taken that the skin is not folded in between the 
fragments. 

When the fragments are not much, or at all separated, and conse- 
quently no such force is required to draw down the upper fragment, and 
when, from the nature of the injury, there is little cause to anticipate 
much swelling, a splint may be employed, constructed like that recom- 
mended by Sir Astley Cooper, made of light wood, curved to fit the 
limb, or of gutta-percha, gum shellac cloth, or sole leather. This should 
be covered with a flannel or cotton sack, and then secured in place by a 
roller. The sack will enable the surgeon to stitch the roller to the 
splint, and he can thus employ effectively the oblique and figure-of-8 
turns about the elbow-joint. Indeed, the latter method will prove ade- 
quate in most cases, while it is less cumbrous than that which I have 
first described as being required when the separation is very great, and 
the injuries unusually severe. 

Plaster of Paris, and any other form of immovable dressing, expose 
the patients to the dangers of gangrene and anchylosis, and ought, under 
no circumstances, to be employed. 

The dressing ought, no doubt, to be applied immediately, since, if we 
wait, as Boyer seems to advise, until the swelling has subsided, it will 
be found much more difficult to straighten the arm completely than it 
would have been at first, and the olecranon process will be more drawn 
up and fixed in its abnormal position. Something will be gained by 
these means, adopted early, even if the bandage cannot be applied 
tightly ; and moderate bandaging will not in any way interfere with the 
proper and successful treatment of the inflammation. We must always 
keep in mind, however, the fact that the fracture being usually the 
result of a direct blow, considerable inflammation and swelling around 
the joint are about to follow rapidly ; and on each successive day, or 
oftener if necessary, the bandages must be examined carefully, and 
promptly loosened whenever it seems to be necessary. For this purpose 
it is better not to unroll the bandages, but to cut them with a pair of 
scissors, along the face of the splint, cutting only a small portion at a 
time, and as they draw back, stitch them together again lightly ; and 
thus proceed until the whole has been rendered sufficiently loose. 

As soon as the inflammation has subsided, and as early sometimes as 
the fifth or seventh day, the dressing ought to be removed completely ; 
and while the fingers of the surgeon sustain the process, the elbow 
ought to be gently and slightly flexed and extended two or three times. 
From this time forward, until the union is consummated, this practice 



354 FRACTURES OF THE RADIUS AND ULNA. 

should be continued daily, only increasing the flexion each time, as the 
inflammation and pain may permit. If it is thought best, at length, to 
change the angle of the arm, and to flex it more and more, it may be 
done easily by substituting a very thick sheet of gutta-percha for either 
of the outer forms of dressing. 

Dieffenbach has several times, in old fractures of both the olecranon 
and patella, where the fragments were dragged far apart, divided the 
tendons, so as to be able to bring the two portions together, and, by 
friction of them one upon the other, has endeavored to excite such action 
as might end in the formation of a shorter and firmer bond of union. In 
some instances, it is said, considerable benefit was obtained, after all 
other means had failed ; in others, the result was negative. One exam- 
ple of an old ununited fracture of the olecranon is mentioned, in which 
he divided the tendon of the triceps, secured the upper fragment in 
place, and every fourteen days rubbed it well against the lower one ; in 
three months " the union was firm." 1 

The practice, not without its hazards, needs further observations to 
determine its value. 

Separation of the Olecranon while in its Epiphyseal State. — Recently 
a gentleman called upon me with his son, aged seven years, who had 
an unreduced dislocation of the radius and ulna backwards of nine weeks' 
standing. While reducing this dislocation, it being necessary to flex the 
arm forcibly, the epiphysis constituting the olecranon process gave way, 
and became separated from one-half to three-quarters of an inch. This 
is the only example of separation of this epiphysis which has come to 
my knowledge. I have, however, twice since broken the olecranon in 
attempts to reduce old dislocations of the radius and ulna backwards, 
and I have not regretted the occurrence, since it enabled me to reduce 
the dislocations without cutting the triceps. 



CHAPTEE XXIY. 

FRACTURES OF THE RADIUS AND ULNA. 

Causes.- — In a majority of the examples of this fracture seen by me, 
which have been of such a character as to warrant an attempt to save 
the limb, the accident has been occasioned by a fall upon the palm of the 
hand while the arm was extended in front of the body. Yet this cause 
is not so constant as in fractures of the radius alone, since a considerable 
number have been occasioned by direct blows ; and if we were to add to 
this estimate all of those bad compound fractures which have demanded 
immediate amputation, the proportion of fractures occasioned by direct 
and indirect blows might be found to be pretty nearly balanced. 

1 Dieffenbach, American Journal of the Medical Sciences, vol. xxix. p. 478 ; from 
Casper's Wochenschrift, Oct. 2, 1841. 



FRACTURES OF THE RADIUS AND ULNA. 355 

Point of Fracture, Character, Direction of Displacement, etc.- — In a 
record of seventy-two fractures of both bones, not including gunshot 

Fig. 114. 




Fracture in the middle third. 



fractures, or those demanding immediate amputation, I have found six 
broken in the upper third, thirty-one in the middle third, and thirty-five 
in the lower third. 

In one case the radius was broken three-quarters of an inch above 
its lower end, and the ulna about one inch below the coronoid process. 
Four of the fractures belonging to the lower third were probably epi- 
physeal separations. 

Fifty-eight were simple, eight compound, one was comminuted, three 
both compound and comminuted, one complicated with a fracture of the 
humerus, and one with a partial luxation of the lower end of the radius. 
With three exceptions, all of these more serious accidents were arranged 
among fractures of the lower third, and generally the bones had been 
broken near the wrist. 

Partial fractures have been frequently observed in children, but hav- 
ing treated of these accidents fully in the general chapter on Incomplete 
Fractures, I shall not think it necessary to make any further allusion to 
them in this place. 

Prognosis. — Generally these bones unite in from twenty to thirty 
days ; but I have seen the union occasionally delayed considerably 
beyond this time, and this delay has occurred especially in the case of 
the radius. Thus, in three cases of compound and comminuted fracture, 
the ulna united within four or five weeks, while the radius did not unite 
until the ninth or tenth week. Twice in simple fractures the ulna has 
united in the usual time, but the radius not until the sixteenth week. 
Once the ulna has united promptly and the radius remained ununited at 
the end of two years, at which time I practised resection of the broken 
ends of the radius, and union was speedily established. 

On the other hand, I have once seen the union delayed four months 
in the case of the ulna, when the radius had united in the usual time ; 
and in one example of compound fracture both bones refused to unite 
until after the fifth month. Muhlenberg has recorded thirty-seven cases 
of delayed and non-union of both bones, out of a total of six hundred 
and fifty-six similar examples in all the long bones. 

A majority of the whole number seen by me have united without any 
appreciable deformity, and fifteen are known to have left some marked 
defect, while two have resulted finally in the loss of the arm. Of the 
remainder I cannot speak positively. 

I have seen the fragments deviate slightly in almost every direction, 
but most often it has been noticed that the deviation was to the radial or 



356 



FEACTURES OF THE RADIUS AND ULNA. 



Fig. Ill 



Fig. 116. 



ulnar skies. Thus, in three examples, two of which had been compound 
fractures, the bones have united in such a position as that from the point 

of fracture downwards the forearm has 
been deflected to the ulnar side, and a 
marked projection has been left at the 
seat of fracture on the radial side ; 
while in two examples, both of which 
were simple fractures, exactly the oppo- 
site condition has obtained, the lower 
part of the forearm being deflected to 
the radial side. 

In most cases the hand has been left 
with some tendency to pronation ; in 
many instances this tendency was very 
slight and scarcely appreciable, but in 
others it has been quite marked, so that 
the patients have been wholly unable 
to supine the forearm except by a mo- 
tion of the humerus in its socket. 

From what has been said, it must be 
seen that the prognosis in these acci- 
dents takes the widest range ; for while 
a larger proportion than in the case of 
almost any other of the long bones, 
unite without any appreciable deform- 
ity, a considerable number delay to 
unite, or do not unite at all, and some, even where the fracture is most 
simple, result in the complete loss of the limb. I am not now speaking 
of those more severe accidents in which the limb is at once condemned 
to amputation, and which, in the case of the arm, are numerous ; but, as 
I have already mentioned, our observations here apply only to cases 
which came under treatment with a view especially to the fracture. 

I shall state the facts more fully, and then perhaps we shall think it 
proper to inquire why, when, as a rule, the treatment is found to be so 
simple and successful, occasionally, and pretty often indeed, it results 
so disastrously. 

A boy, aged about ten years, fell from a tree, April 22, 1856, frac- 
turing the right forearm near the lower end of the middle third. It 
was evident that he had fallen upon the palm of his hand, as the lower 
fragments were inclined backwards, and one of the bones had been 
thrust through the skin on the front of the arm. 

It was at first dressed carefully by Dr. Wilcox, but the father of the 
lad, on the following day, placed him under the care of an empiric. 

Six days after the fracture occurred I was called to see him, with 
several other gentlemen. He was then suffering under a severe attack 
of tetanus which had commenced the night before. His arm was much 
swollen and very painful. He died the same evening. 

I was unable to learn very particularly what had been the treatment 
since the patient was seen by Dr. Wilcox, except that the bandages had 
been most of the time very tight, and that the empiric had applied 



Fracture in the 
lower third. 



Union with slight lat- 
eral displacement. 



FRACTURES OF THE RADIUS AND ULNA. 357 

stimulating liniments, the boy constantly complaining greatly of the 
pain. I found the arm done up in a most slovenly manner with several 
narrow splints, underlaid with loose and knotty fragments of cotton- 
batting. 

We removed all of these immediately, and laid the arm upon a cushion 
supported by a board, to both of which the arm was lightly secured by 
a few turns of a bandage ; cool water lotions were diligently applied, 
and chloroform administered by inhalation ; but the fatal event was 
delayed only a few hours. 

I shall not stop to inquire the cause of a result so unfortunate, where 
the treatment has been so palpably unskilful. 

I have already mentioned one case of gangrene of the hand, after a 
fracture of the lower part of the humerus. Norris, in a note to the 
American edition of Listorf s Surgery, mentions a case which came 
under his observation in the Pennsylvania Hospital, the fracture having 
taken place just above the condyles ; and still another has been related 
to me lately. I have brought together also no less than six cases of 
sloughing of the arm, after fracture of the radius, and one of sloughing 
from tight bandaging, where the radius was supposed to be broken, 
although the dissection proves that it was not. 

Robert Smith says that similar cases have been recorded in the Grazette 
Medicate. To these I shall now add eight examples of sloughing after 
fracture of both radius and ulna ; making a total of eighteen cases in the 
upper extremities, in addition to those reported in the Grazette Medicate, 
an exact account of which I have not seen. 

John McGrath, aet. 9, fell, July 2, 1847, from a ladder, about thirty 
feet to the ground, breaking the right radius and ulna in their middle 
thirds. A surgeon was in attendance about four or five hours after 
the accident occurred. He then reduced the fractures and applied two 
broad splints, one on the palmar and one on the dorsal surface of the 
forearm. Whether a roller was first applied to the arm or not, I am 
unable to say. The splints were secured in place by a roller and the 
arm laid in a sling. 

The third day was our national holiday, and the patient was not 
visited. Nor was he seen on the fourth day, not being found at home. 
On the fifth day the surgeon removed the bandages and found the arm 
gangrenous ; and within an hour afterwards I was requested to see it 
also. 

I found him lying in a miserable apartment, with his right arm 
resting upon a pillow. The arm, forearm, and hand were gangrenous 
through their whole extent; and the skin of the right side, on the 
front of the chest, had assumed a dusky color, the extreme margin of 
which was indicated by an abrupt crescentic line. The thumb and 
fingers were black. His countenance was bright and cheerful, and his 
mind intelligent ; pulse 75, and soft ; tongue clean. He had slept un- 
disturbed the night before, and he had all along felt perfectly well, 
except that he had a slight diarrhoea. I was assured by the surgeon, 
and by all of the family, that the bandages had not been applied 
tightly ; but we were told that on the third day of the accident, having 
been locked into the house by his mother, who was a peddler, he 



358 FRACTURES OF THE RADIUS AND ULNA. 

climbed out of the window ; and that during all of that and most of 
the following day he was running about the streets firing crackers, 
during most of which time his arm was removed from his sling and 
hanging by his side. On the morning of the fourth day his mother 
noticed that his fingers were black, but she thought they were stained 
with powder. 

We ordered him to take one-quarter of a grain of opium every four 
hours, and applied a yeast poultice to the arm. On the seventh day 
the gangrene was still extending, and the pulse was 124 ; yet he con- 
tinued to feel well and to eat as usual. On the tenth day the line of 
demarcation had commenced opposite the shoulder-joint ; and the cres- 
centic discoloration on the breast, which had at first spread rapidly until 
it covered nearly the whole upper half of the chest, was quite faint, in 
some parts almost lost. 

In a few days more he was removed to the county almshouse, the 
separation continuing rapidly to take place until the arm fell ofF at the 
shoulder-joint ; after which he made a good recovery. 

A child, two years and three months old, had fallen from a chair 
upon the floor, a distance of about two feet. A German physician 
being called, found, as he believes, a fracture of both bones of the left 
arm. The fracture was near the middle. He immediately applied a 
roller from the fingers to the elbow, and over this three narrow splints 
made of the wood of a cigar-box. One of these was laid upon the 
palmar, one upon the dorsal, and one upon the radial side of the fore- 
arm, and the whole were bound together by another roller. From this 
time until the tenth day the child continued to play about on the floor. 
Ten days after the accident occurred the doctor noticed that the ulnar 
side of the little finger was blue. The bandages were immediately re- 
moved, and were never again applied tightly. 

Three or four days after, I was requested to see the arm with the 
attending physician. The gangrene had continued to extend, involving 
now the whole of the little finger and most of the thumb. There were 
also gangrenous spots over the hand and forearm, extending to within 
one inch from the elbow-joint ; these spots were more numerous in front 
and on the back of the forearm, and seemed to correspond to the pres- 
sure of the splints. The hand was much swollen, and also the arm 
above the line of the gangrene. The sloughs had already commenced 
to be thrown off, and the gangrene was only extending in a few points. 
The child appeared well and rather playful, except w r hen the arm w r as 
being dressed. I ordered a yeast poultice, and a nourishing diet. 

I have since learned that the arm and a large portion of the hand were 
finally saved. 

About the year 1865, as near as I can remember, a lad aged about 
nine years was brought to the Long Island College Hospital Dispensary, 
with a fracture of the radius and ulna. It was dressed by the visiting 
surgeon with splints and bandages. He did not return to the Dispensary 
as directed to do, and on the third or fourth day portions of the arm and 
hand were found in a gangrenous condition. 

In March, 1867, I was consulted by the parents of D. C, of Catta- 
raugus Co., N. Y., on account of a serious distortion of the hand and 



FRACTURES OF THE RADIUS AND ULNA. 359 

forearm, caused by sloughing, splints and bandages having been applied 
by her surgeon for a supposed fracture ; but, when examined by me 
about ten weeks after the accident, there was no evidence that the bones 
had ever been broken. She complained to her surgeon that the bandages 
w T ere too tight, but he thought otherwise, and they were not removed 
until the third day, when the gangrene had already occurred. The 
child was five years old at the time of the accident. 

A young man, get. 20, suffered a simple fracture of the right radius 
and ulna March 11, 1874. On the same day it was dressed with a 
roller next to the skin and over this the splints. On the following 
day the fingers were black, but the same dressings were continued, 
and they were not removed completely until the next day. He was 
admitted to Bellevue on the 16th, and by courtesy of Dr. Gouley I 
was permitted to examine the arm on the 7th of April. He had then 
lost all of his fingers, except a portion of the thumb, and there was 
extensive sloughing and suppuration along the forearm. His condition 
was very critical. His death took place a few days later. It is worthy 
of remark that, after the first few hours, there was no pain in the arm, 
although the dressing had not been removed. 1 

Alice Thompson, set. 50, fell upon her left hand in March, 1870, caus- 
ing a compound fracture of the radius and ulna, about three inches above 
the wrist-joint. She went at once to one of the New York City Dispen- 
saries, and the surgeon dressed the arm with splints, applying the band- 
ages "snugly." Two clays later she was brought to one of my wards 
at Bellevue, with the back of the hand and most of the forearm in a 
state of gangrene, evidently caused by the bandages. Seven or eight 
days later she died before the house surgeon could reach her, from a 
secondary hemorrhage. 

In the following case there was probably no fracture ; no doubt could 
be entertained, therefore, as to the cause of the gangrene. 

A girl, set. 5, fell upon the palm of her hand in 1866. A surgeon 
saw her within one hour, put on two wooden splints, with cotton batting 
laid loosely underneath, securing them with a roller. Half an hour after 
it was dressed the fingers were blue, and the pain was so great that the 
surgeon was recalled. On his arrival he said it was not too tight. On 
the following day the condition was the same, but the surgeon refused to 
loosen the dressings. Two days later he removed the bandage, and found 
a slough extending nearly the whole length of the palmar surface of the 
forearm. Some months later I found the arm straight, but the hand 
much distorted by the cicatrix. 

I have now to relate a case in which sloughing and death occurred as 
the consequence of a tight bandage, the patient being under my own 
charge. 

James Brachen, set. 22, was admitted to ward 12, Bellevue Hospital, 
April 1, 1871, with a fracture of the left forearm, near its middle, caused 
by the kick of a horse on the day before. On the same clay I dressed 
the fracture before the class of medical students in the hospital, using a 
palmar and dorsal board splint, covered and stuffed with cotton batting, 



360 FEACTUEES OF THE RADIUS AND ULNA. 

according to my usual method ; securing the splints with a roller, includ- 
ing the hand and forearm. The arm was then placed in a sling and he 
was sent to his ward. The following clay being Sunday, I did not visit 
the hospital. On Monday I inquired for him, and learned that he was 
out walking in the yard. Tuesday I met him, returning from a walk in 
the yard, just as I was leaving the ward. He was apparently in perfect 
health, but, as I stopped him a moment to look at his arm, I saw that the 
hand was swollen and purple. The dressings were immediately removed, 
and the patient placed in bed. There were upon the arm two spots looking 
like superficial sloughs. He was suffering no pain. The gangrene subse- 
quently extended until it involved a large portion of the hand and fore- 
arm, and on the eighteenth day after the receipt of the injury he died. 

I will submit the case without comment, except to say that a careful 
and daily observation of the condition of the hand, and a prompt removal 
or loosening of the dressings when the hand first showed symptoms of 
arrest of circulation, would probably have prevented this disastrous re- 
sult. The splints and bandages were removed the first time I saw him 
after the original dressings had been made, bat this was too late ; some one 
should have seen the approaching cloud and before it was ready to burst. 

South also says that he has seen one or two instances of mortification 
produced by splints applied too tightly, and previous to the accession of 
the swelling after fracture, and which had not been loosened as the swell- 
ing increased. 1 

How shall we explain the frequency of these accidents after fracture 
especially of the forearm ? 

Malgaigne, speaking of fractures of both bones of the forearm, re- 
marks that " when the displacement is considerable, or more especially 
when the outward violence has been excessive, we frequently see follow 
a very intense inflammatory swelling, and there is no fracture which com- 
plicates itself so easily with gangrene under the pressure of apparatus." 2 

Says Nelaton : " If we make choice of the apparatus of J. L. Petit, 
it is necessary that it shall not be applied too tightly, for, as Professor 
Roux has long since remarked, fractures of the forearm are those which 
furnish most of the examples of gangrene in consequence of an arrest 
of the circulation. This is easily understood, if we consider on the one 
hand the superficial position of the two principal arteries of the forearm, 
and on the other the disposition of the apparel, which must almost infal- 
libly compress the arteries to a great extent." 3 

I do not think that this accident is clue always to the negligence of 
the surgeon. It may be clue many times to the carelessness of the parents 
or of the patient himself ; as in the case of the boy who came under my 
own observation, and who lost his arm at the shoulder-joint. Sometimes 
also it may be due rather to the severity of the original injury, which, 
the experience of every surgeon will prove, is occasionally competent to 
the production of such bad results. A number of unfortunate circum- 
stances may have concurred, such as a severe injury, especially where 

1 South, note to Chelius's. Surg., vol. i. p. 69. 

2 Malgaigne, Frac. et Disloc. torn. i. p. 589. 

3 Nelaton, Pathologie Chirurgicale, p. 735. 



FRACTURES OF THE RADIUS AND ULNA. 361 

the skin has remained unbroken and the effused blood has had no oppor- 
tunity to escape — the broken bone may have rested against the trunk of 
a main artery, causing an arrest of its circulation — the constitution may 
be impaired by previous illness, or it may be suffering under the shock 
of the injury ; yet that it may be and too often is the result of maltreat- 
ment, on the part of the surgeon, is undeniable. It is proper, however, 
to discriminate between the responsibility which attaches to the surgeon 
as the true exponent of the state of his art, and that which attaches to 
the art itself as taught by the masters. 

The old surgeons applied first a roller to the hand and forearm, and 
over this their various splints. J. L. Petit thought he had made a valu- 
able improvement upon this simple plan, by laying over the roller a 
compress and splint ; the compress being intended to press between the 
bones, and to antagonize the action of the roller in drawing the fragments 
toward each other. Duverney believed that this object would be best 
accomplished by placing the pad against the skin, and under a circular 
compress; while Desault declared all of these modes inefficient, and an- 
nounced a method which he regarded as accomplishing at once and com- 
pletely all of the indications ; the sole peculiarity of which method 
consisted in placing graduated pads against the skin, and securing them 
in place by a roller. Boyer adopted the same method without any 
modifications, and Mr. Hind, in his illustrations of fractures, already 
referred to, has seen fit to recommend the same, at least in fractures of 
the radius. 

It is quite obvious that between these various methods there remains 
very little if anything to choose, the differences being too trifling and 
unessential to claim serious consideration. Each alike is inadequate to 
accomplish any amount of useful pressure between the fragments ; each 
alike is calculated to bind the bones one against the other, and each 
alike exposes to the danger of ligation and of gangrene. 

Says M. Dupuytren : " The practice of rolling the arm before the 
splints are applied, whether internal or external to the pads and com- 
presses, is eminently mischievous ; and instead of fulfilling, directly 
counteracts, the indications which it is most important to keep in view 
in the treatment of fractures of the forearm." 

And notwithstanding the same sentiment has been reiterated by Vel- 
peau, Malgaigne, Xelaton, Samuel Cooper, Bransby Cooper, Erichsen, 
Amesbury, Gibson, and others, yet we find the great surgeon of Heidel- 
berg, Chelius, recommending the roller to be applied under the splints, 
after the manner of Desault: while Liston, Syme, and Fergusson, who 
perhaps represent the Edinburgh school, use only pasteboard splints 
above the compresses, over which is immediately applied the roller ; 
a practice which differs very little from that recommended by Desault, 
and is equally obnoxious to criticism. 

Among the American surgeons, I believe, the advice and practice of 
Dupuytren have received almost universal assent, only that we have 
always employed splints much wider than those recommended by this 
distinguished surgeon. I cannot therefore agree with my accomplished 
countryman, Dr. Reynell Coates, if in the following paragraph he 
means to imply that American surgeons generally adopt Desault' s treat- 
24 



362 FRACTURES OF THE RADIUS AND ULNA. 

ment. Such at least is not my experience. " It would be wrong," 
says Dr. Coates, " not to bear testimony, on every possible occasion, 
against the folly so universally prevalent, that induces surgeons to 
apply a bandage directly to the forearm before applying splints in in- 
juries of this character. We have often asked for a rational explana- 
tion of this practice, without effect. It is directly at war with the ac- 
knowledged indications in the coaptation of the fragments, and when 
the object of the whole apparatus is to thrust asunder their extremities, 
it commences by binding them together. Few plans in surgery are more 
generally followed ; none can be more absurd." 

Of the estimate placed upon the roller by M. Mayor, the reader will 
judge by a reference to the passage which I shall quote further on, when 
I shall speak of the value of the interosseous compresses. 

Amesbury and Bransby Cooper use no rollers at all — not even to se- 
cure the splints in place, they being made fast to the forearm by straps 
or tapes. 

Mr. Amesbury and Mr. South also endeavor to give to their splints 
an appropriate shape, by having them constructed with more or less 
convexity. It must be noticed, however, that the practice of these two 
gentlemen is very dissimilar, for while Mr. South applies the convex 
surface of his splint to the interosseous space, Mr. Amesbury reverses 
this plan, and applies the concave surface directly to the skin. 

As to the width of the splints, surgeons are also very generally 
agreed, at the present day, that they ought to be wider than the arm, 
so as to prevent the roller or the tapes from resting against its sides. 

I do not intend to deny peremptorily, and without qualification, the 
value of the graduated compresses, which, as we have seen, are usually 
laid along the interosseous space to press the fragments asunder. It is 
necessary, however, to caution the surgeon against their injudicious use. 
M. Nelaton has well remarked of the apparel employed by J. L. Petit, 
that it must inevitably compress, to a great extent, the arteries of the 
forearm ; and the remark is applicable, in only a less degree, to all of 
those other plans in which the compress is employed. And I suspect 
that to this portion of the dressing, quite as much as to any other cause, 
are due those frightful accidents of which we have already spoken. 
The arteries are not only exposed, from their superficial position, to 
pressure from a compress, but, in addition to this, it will be noticed 
that the two principal arteries, the radial and the ulnar, are situated 
upon a broad and flat surface of bone, along which this pressure must 
operate most advantageously. So early as the year 1833, M. Lenoir, 
in his inaugural thesis at Paris, called attention to this danger, and 
from time to time surgeons have continued to advert to it, but they 
have seldom given to its consideration that prominence which its im- 
portance deserves. 

I have observed another fact in this connection : when this compress 
is extended low down on the palmar surface, within an inch or two of 
the wrist-joint, it soon becomes excessively painful, and sometimes even 
wholly insupportable, in consequence of the pressure made upon the 
median nerve ; and I find myself always obliged to exercise great care 
in the adaptation of the pads at this point. For this reason alone, I 



FRACTURES OF THE RADIUS AND ULNA. 363 

believe, in case of a fracture near the base of the radius, the lower 
fragment, if it were thrown toward the ulna, could not be retained in 
its place by graduated compresses. 

In short, finding that broad splints, properly covered and padded, 
answer very well to crowd the muscles into the interosseous space, so 
far as it is proper to do so, and believing that this mode is less painful 
and less dangerous, I never resort to graduated compresses, nor can I 
appreciate their necessity, or indeed their utility. Mr. Lonsdale also 
concurs with me in attaching very little value to this part of the accus- 
tomed apparel. 

But listen to the surgeon of Lausanne, M. Mayor: "What signify 
graduated compresses placed between the bones of the forearm for the 
purpose of separating them from each other ? These bones will not 
have that constant tendency to approach each other which has been 
supposed, provided, first, that they have been well reduced ; second, 
that for the purpose of maintaining them in position we do not make 
use of a preliminary circular bandage, whose action is an absurdity ; 
and, in short, provided we make the retentive means act chiefly upon 
the palmar and dorsal surfaces of the forearm." 1 

M. Mayor proceeds to declare these convictions to be the result of his 
own experience, both in the treatment of simple and compound fractures 
of the forearm, and he intimates that in the use of the circular bandage 
with compresses, surgeons seem to have rolled the arm into a cylinder 
and drawn the bones together, in order that they might tax their in- 
genuity to discover some means to again separate them. 

Surgeons have generally, after the splints have been applied, placed 
the forearm in a position of semi-pronation, or midway between supina- 
tion and pronation, so that the radius should be uppermost ; it being 
assumed that in this position the two bones are most nearly parallel, and 
least inclined to displacement. Such, indeed, was the practice of Hip- 
pocrates, Paulus iEgineta, Celsus, Albucasis, and of most surgeons down 
to this day ; but Lonsdale, Robert Smith, Nelaton, and South have 
lately called in question the correctness of this mode of dressing, at 
least when it is adopted as a universal rule. 

I have before mentioned, when treating of fractures of the ulna, that 
M. Fleury had, in one instance, been unable to bring the fragments into 
apposition except by forced supination of the forearm ; and in certain 
fractures we have seen the same position recommended by Lonsdale. 

Says Mr. South, in a note to Chelius : "In fractures of both bones 
the forearm is best laid supine ;" and Nelaton declares that in fractures 
of the radius and ulna at any point of their upper thirds it will be neces- 
sary to supine the arm, both in the reduction and during the subsequent 
treatment ; but that in fractures of the inferior two-thirds we may place 
the limb in a condition of semi-pronation. 

It seems very probable, however, that both of these gentlemen have 
received their suggestions from Mr. Lonsdale, who, as we have already 

1 Bandages et Appareils a Pansements, on Nouveau Systeme de Deligation Chi- 
rurgicale, par M. Mathias Mayor, Chirurg. en Chef de l'Hopital de Lausanne, Swit- 
zerland. Paris ed., 1838, p. 345. 



364 FRACTURES OF THE RADIUS AND ULNA. 

seen, has treated the question very much at length, and who has finally 
declared his decided preference for the supine position in the treatment 
of all fractures of the forearm. His arguments are certainly very in- 
genious, and as applied to fractures of. the radius above the insertion of 
the pronator radii teres, they seem altogether conclusive ; and, indeed, 
they commend themselves very strongly to our judgment, as applied to 
all fractures of the forearm. They are sustained also by the results of 
his own experience, and I see no good reason why they should not be 
more thoroughly examined and tested by other surgeons. The advan- 
tages which he claims for this method are, more perfect coaptation of the 
broken ends, less liability of the fragments to encroach upon the inter- 
osseous space, and consequently less danger of anchylosis between the 
bones and of non-union of the fragments, more complete restoration of 
the power of supination, and less tendency to lateral distortion, or of 
falling off to the ulnar or radial sides. 

My own cases, treated by the usual method, have shown that while 
supination is frequently impaired, and sometimes entirely lost, pronation 
is rarely affected ; and that lateral displacements are much more common 
than displacements forwards or backwards. How this position, semi- 
pronation, may tend to the production of a permanent pronation, I have 
fully explained when speaking of fractures of the head of the radius ; 
and the influence of the same position, the forearm resting upon its 
ulnar margin in the sling, in the production of a lateral deviation, is also 
easily understood. If the arm rests upon the sling so that its weight 
bears more upon the point of fracture than upon the extremities of the 
bones, then the ulna, or both ulna and radius, will incline gradually to 
the radial side, and the hand will fall oif to the ulnar side ; or if the 
sling rests under the wrist or hand chiefly, the hand will ascend to the 
radial side, and the broken ends of the two bones will project to the 
ulnar side. 

If this plan is adopted, viz., laying the hand and forearm upon its 
back, instead of upon its ulnar margin, the elbow should remain at the 
side, the humerus falling perpendicularly from its socket; and the fore- 
arm should rest in the sling directed forwards from the body. 

The following is the method usually employed by the author: — 

Two thin, but firm, wooden splints are prepared, of uniform breadth, 
sufficiently wide that when the roller is applied it shall touch only lightly 

the radial and ulnar margins of the 

igsraa forearm. The palmar splint should be 

long enough to extend from the bend 





of the elbow, the arm being flexed, to 
the metacarpo-phalangeal articulations, 
the fingers being flexed. The dorsal 
splint should be a little shorter, or of a length to extend from the base 
of the olecranon process to the carpus. Both of these splints must be 
covered with cloth, and properly padded with cotton batting; taking 
care to leave but little of the cotton placed where it might press upon 
the radial and ulnar arteries and median nerve ; that is, at the front of 
the wrist. 

The splints, being carefully fitted, are applied while the forearm is 



FRACTURES OF THE RADIUS AND ULNA. 365 

held at a right angle with the arm, and in a position midway between 
pronation and supination, one to the palmar and the other to the dorsal 
surface of the forearm, and secured with a roller. There must be no 
pressure against the humerus at the bend of the elbow ; and the fingers 
must be flexed easily over the lower end of the palmar splint. The 
dorsal splint should not extend beyond the lower end of the radius and 
ulna. It is understood, of course, that while the splints are being 
secured in place, extension and counter-extension are maintained for the 
purpose of securing coaptation of the broken extremities as far as possi- 
ble. The dressing being completed, the forearm is suspended in a sling. 

Finally, whatever may be the mode of dressing, let me repeat the 
injunction to examine the arm frequently. No surgeon can do justice 
to himself, or to his patient, who does not look at the arm at least once 
in twenty-four hours during the first ten or fourteen days, and in some 
cases the patient ought to be seen twice daily. 

When the fracture is compound, it is often quite impossible to retain 
the forearm in the half-pronated position ; since, when thus placed, and 
onty slightly supported, as it must necessarily be, it inevitably falls over 
upon its palmar surface. 

There can be no doubt that in such a case we ought, from the first, 
if it is found practicable, to place it upon its back, in a position of com- 
plete or nearly complete supination. For this purpose, a single broad 
splint, carefully cushioned, and covered with oiled cloth, is the most 
suitable. Upon this the forearm is to be laid, and secured gently with 
a few turns of the roller. If the patient is able to do so, and wishes to 
walk about, the board may be suspended to the neck, as recommended 
by M. Mayor. 

I have said that we ought, in cases of compound fracture, to lay the 
forearm upon its back, if practicable. I am sure, however, that the 
surgeon will find very many patients who cannot endure this position, 
and he may be compelled, therefore, to lay the limb upon its palmar 
surface, or to leave it to assume any other position in which it may be 
the most at ease. In conclusion, I desire again to call attention to the 
splint employed by Dr. Scott, and of which an illustration is given in 
the chapter w T hich treats of fractures of the radius. 

Recently, in a letter from Dr. G. W. Burke, of New Castle, Indiana, 
I am informed that in the case of an oblique fracture of both bones of 
the forearm, occurring in a man thirty years of age, and at the junction 
of the lower and middle third, the fragments were thrust downwards and 
outwards until they had nearly penetrated the skin. Finding, after 
repeated efforts, that he was unable to extricate them from the muscles 
and fascia which they had penetrated, he made an incision, exposed the 
bones, and replaced the fragments. The arm was subsequently dressed 
in the usual way, and he made a good recovery. Resection of the frag- 
ments was not required. The practice in this case was no doubt sound, 
inasmuch as in no other way could the bony union of the fragments have 
been assured. 

Of the 37 examples of delayed and non-union recorded by Muhlen- 
berg, 30 were subjected to treatment. Of 4 treated by manual friction, 
1 was cured and 3 failed. One treated by section was cured. Of IT 



366 FRACTUBES OF THE METACARPAL BONES. 

treated by resection, 11 were cured and 6 failed ; 4 were treated by 
drilling, and all failed. Of 4 treated by mechanical appliances and im- 
mobilization, 2 were cured and 2 failed. 1 



CHAPTEE XXV. 

FRACTURES OF THE CARPAL BOXES. 

The few cases of fracture of the carpal bones which have come under 
my observation were, without exception, compound and complicated, 
and have resulted in the complete loss of the hand, or in some less 
serious, but never inconsiderable, mutilation or maiming. 

In no case has a treatment been adopted which might be regarded as 
having reference to the fracture, or the purpose of which was to insure 
apposition and union of the fragments. 

It may be proper to assume in a matter so easily comprehended, what 
actual and recorded experience has not proven, namely, that simple 
fractures of these bones will demand very little surgical interference, 
and that they will unite generally without much displacement, and with- 
out any considerable maiming. It is, indeed, quite probable that some 
degree of anchylosis between their adjacent surfaces will occur, yet even 
in the normal condition they enjoy so little motion as to render it doubt- 
ful whether its complete loss would be very sensibly felt. 

In cases of comminuted, compound, and otherwise complicated fractures 
of the carpal bones, which accidents are sufficiently common, the surgeon 
has only, I conceive, to follow carefully those general or special indica- 
tions which may happen to be present, the precise character of which it 
would be difficult to anticipate, and for the treatment of which it would 
be unsafe to attempt in a written treatise to provide. 



CHAPTEE XXVI. 

FRACTURES OF THE METACARPAL BONES. 

Development of Metacarpal Bones. — These bones are each formed 
from two centres of ossification. In the case of the metacarpal bones of 
the four fingers there is one centre for each shaft, and one for each 
distal extremity; but in the case of the metacarpal bone of the thumb 
there is one centre for the shaft and one for the proximal extremity. 
All these epiphyses unite with the shafts at about the twentieth year. 

1 Muhlenberg, Agnew's Surg., op. cit., vol. i. p. 805. 



FRACTURES OF THE METACARPAL BONES. 367 

Causes. — They are generally broken by direct blows ; and in that 
case the injury is often of such a character as to demand amputation, 
and does not therefore belong to that class of accidents of which it is 
the purpose of this volume to treat, Not an inconsiderable number, 
however, are the results of indirect blows, and especially of blows upon 
the knuckles received in pugilistic encounters. Thus, in a record of 
sixteen fractures, I find this cause assigned in seven; in one other in- 
stance it was occasioned by falling upon the clenched fist, and in one 
by striking a board ; so that the fracture has resulted from a blow upon 
the ends of the bones in nine of the sixteen examples. 

Point of Fracture; Direction of Displacement; Symptoms. — Once 
the fracture has occurred in the metacarpal bone of the thumb ; eight 
times in the metacarpal bone of the index finger; once in the second 
finger ; three times in the ring finger, and three times in the metacarpal 
bone of the little finger. Two of those belonging to the ring finger, and 
the three occurring in the little finger, were produced by blows with the 
clenched fist, and in each instance the fracture was in the lower or distal 
third of the bone. Three of the fractures of the metacarpal bone of 
the index finger were produced also in the same way; two of which 
were near the middle of the bone, and one near the proximal end. Of 
the whole number, seven were broken through the lower third, five 
through the middle, and four through the upper third. 

In every instance where the bone is known to have been broken by a 
blow upon the knuckles, the distal end of the distal fragment was thrown 
toward the palm, and this fragment was salient backwards at the point 
of fracture. 

In the following case the bone was probably separated at the 
epiphysis. 

Thomas Rose, set. 8, fell down a flight of steps, September 11, 1855, 
breaking the metacarpal bone of the index finger of the right hand near 
its lower extremity, and apparently at the junction of the epiphysis 
with the diaphysis. 

I saw the lad about sixteen hours after the accident. The lower frag- 
ment, projecting abruptly into the palm of the hand, could be easily 
replaced, or with only moderate effort, yet immediately when the support 
was removed it would become displaced. There was no crepitus. 

It was dressed very carefully with a splint and compress ; but, not- 
withstanding our continued efforts to keep the fragments in place, the 
epiphysis united considerably depressed toward the palm. 

In one instance, also, I think the bone was rather bent, or partially 
fractured, than broken completely. This was the case of fracture of 
the metarcarpal bone of the ring finger, produced in a gymnasium by 
striking with the clenched fist against a board, and to which I have 
already alluded. I did not see the young man until four weeks after 
the accident, when I found the lower end of the bone depressed toward 
the palm, and the angle made at the point of fracture was rather 
rounded and quite smooth ; it was also tender at this point, but the 
bone was firm and unyielding. Four years after I was permitted to 
examine it'again, and I found the same slight deformity still continuing. 

A partial explanation of the fact that the distal end of the distal 



368 FRACTURES OF THE METACARPAL BONES. 

fragment is generally displaced toward the palm, may be found in the 
natural curve of these bones, which is such that when the fracture has 
been produced by a counter-stroke, the distal end would almost neces- 
sarily be driven in this direction ; and a farther explanation has been 
suggested by Mr. B. Cooper, namely, the action of the interossei. 

Results. — Generally, when the fracture is simple, and the displace- 
ment is not considerable, the nature of the accident is overlooked, and 
some deformity must inevitably ensue. In a majority of the cases 
which have come under my observation this has been the fact, and the 
bone has remained slightly bent at the seat of fracture, but without 
affecting in any degree the value of the hand. 

The following example has furnished the most serious result of any 
case of simple fracture of these bones which has come under my notice. 

Louis Mooney, set. 25, struck a man with his clenched fist, Novem- 
ber 4, 1856, breaking the metacarpal bone of the index finger of the 
right hand near its middle. Great swelling and suppuration followed 
the injury. 

February 21, 1857, nearly four months after the injury was received, 
he consulted me. There existed at this time a complete anchylosis at 
the wrist-joint, and partial anchylosis in the fingers. The hand was 
deflected forcibly to the radial side. At the point of fracture the frag- 
ments were salient backwards and quite prominent, but firmly united. 

Even when the existence of the fracture is recognized, it is not always 
easy to retain the fragments in place, as the case of epiphyseal separa- 
tion already mentioned, and the following case, will illustrate. 

Miss E., of Erie Co., N. Y., set. 18, fell, August 7, 1853, striking 
upon her right hand with her fingers forcibly bent into the palm of the 
hand. On the following day she consulted me at my office, and I found 
the metacarpal bone of the ring finger broken about three-quarters of an 
inch from its distal end, and the distal extremity of the fragment de- 
pressed toward the palm. A feeble crepitus, with distinct motion, com- 
pleted the diagnosis. The young lady was very anxious to have a perfect 
hand, and I was determined if possible to accomplish it. Finding that 
the joint end of the distal fragment was constantly disposed to fall 
toward the palm, I constructed a gutta-percha splint for the hand and 
fingers, and after placing a pad directly underneath this fragment, I 
secured it firmly with a roller. From this time until the end of four 
weeks she remained under my care, visiting me as often as once or 
twice a week, and at each dressing I found the distal fragment slightly 
displaced in the same direction as at first, nor was I able ever to make 
it resume completely its position. 

Ordinarily, however, no such difficulty is experienced, and the bone, 
supported by such simple means as we shall presently direct, unites 
quickly and without deformity. 

An engineer was struck by a piece of iron in such a way as to break 
his right forearm and the second metacarpal bone of the same hand. 
The fracture of the metacarpal bone was compound and about three- 
quarters of an inch from its proximal extremity. When he called upon 
me, which was immediately after the injury was received, I found the 
proximal fragment projecting directly backwards, its sharp point rising 



FRACTURES OF THE METACARPAL BONES. 369 

above the skin, into which position it was evidently drawn by the action 
of the extensor carpi radialis longior muscle. By pressure alone it could 
be replaced, but it was much more easily reduced when the hand was 
forcibly carried backwards on the forearm. I therefore secured the 
hand in this position with appropriate splints, and it was maintained in 
this posture during most of the subsequent treatment. Union finally 
took place, but not without some backward displacement. Four months 
after the accident occurred, on the 31st of December, 1858, I examined 
the hand, and found the skin healed over completely, the end of the 
fragment having become rounded and smooth, so as not to give him any 
degree of annoyance. His wrist was as flexible and as strong as before. 
No doubt the projection of the fragment might have been prevented 
entirely by cutting at the point of its attachment the tendon of the 
muscle, but this would have sensibly weakened the wrist-joint, and I 
preferred the alternative of a projection of the fragment. 

Treatment. — With moderate extension made upon the finger corre- 
sponding to the broken bone, while the fragments are forced home by 
firm pressure, the bone may generally be brought at once into line, and 
we may now proceed to adapt a gutta-percha, felt, or thick pasteboard 
splint, to either the whole surface of the back or palm of the hand and 
fingers, while they are held in a position of easy flexion. It is not very 
material to which of these surfaces the splint is applied ; or rather, I 
may say, it ought to be applied to the one or the other according as cir- 
cumstances seem to indicate. It should be well padded, and especially 
at certain points, in order to the more effectual support of the frag- 
ments. It is then to be secured in place with several turns of a roller. 
When either of the metacarpal bones, except those of the great or ring 
finger, is broken, the splint must be wide enough to secure the sides of 
the hand against the pressure of the roller. 

Thus dressed, the hand may be laid in a sling beside the chest, or 
while sitting it may rest upon a table. 

The apparel must be examined daily, and readjusted as often as it 
shall become disarranged, or as a doubt shall arise as to the condition 
of the parts. 

When the fracture is followed by much inflammation, or occurs near, 
and especially if it actually involves a joint, the same precautions must 
be adopted to prevent anchylosis as in the case of similar fractures in 
other bones. 



370 FRACTURES OF THE FINGERS 



CHAPTER XXVII. 

FRACTURES OF THE FINGERS. 

Development of the Phalanges of the Hand. — The phalanges of the 
hand are formed from two centres of ossification, namely, one for each 
shaft and one for each proximal end. Ossification commences in the 
shafts at about the sixth week ; in the epiphyses of the first phalanges 
between the third and fourth years, and in the epiphyses of the two 
last phalanges somewhat later. Complete bony union takes place be- 
tween the epiphyses and the shafts at from the eighteenth to the twen- 
tieth year. 

Causes. — I do not remember to have seen a fracture of one of the 
phalanges produced by a counter-stroke ; I am aware, however, that 
they are occasionally produced in this w T ay, as by falling upon the ends 
of the fingers, and especially by the stroke of a ball in the game of base. 

The fact, however, that they are generally the consequence of a direct 
blow, and that the finger bones are small and only protected by a thin 
covering of skin and tendons, renders them peculiarly liable to commi- 
nution and to other serious complications. Thus, in a record of thirty 
fractures, only eighteen were sufficiently simple to warrant an attempt 
to save them ; and only five are recorded as simple fractures without 
complications. 

Point of Fracture and Direction of Displacement. — In the following 
case there was probably an epiphyseal disjunction. A lad four years 
old was admitted to the Hospital of the Sisters of Charity, Dec. 24, 
1849, with a simple fracture of the first phalanx of the ring finger of the 
left hand ; the fracture being at the proximal end of the bone, and at the 
junction of the epiphysis with the shaft. 

The finger was so much swollen at first, that no dressings were ap- 
plied until the fifth day, at which time a gutta-percha splint was moulded 
to it carefully. It resulted in a perfect cure. 

I have never seen the fragments much overlapping, except in one 
instance. Frequently there has been no perceptible displacement what- 
ever ; but generally there will be found a slight displacement in the direc- 
tion of the diameter of the bone. 

The case to which I refer as presenting an extraordinary overlapping 
was that of an Irish laboring woman, aged about thirty-five years, who, 
having fallen down a flight of steps, broke the first phalanx of the thumb 
below its middle. Dr. Congar was first called on the day following the 
accident, but was unable to reduce the fracture, and on the same day 
invited me to see the patient with him. The distal fragment w r as dis- 
placed backwards, overlapping the proximal fragment a little more than 
one-quarter of an inch. We made repeated efforts, by pulling upon the 



FRACTURES OF THE FINGERS. 371 

thumb with a sliding noose, and with all the strength of our four hands, 
but to no purpose. The fragments could not be reduced for one mo- 
ment ; and we left the patient as we had found her, only somewhat the 
worse for our violent and repeated extensions and manipulations. The 
finger was already considerably swollen when we began our efforts, and 
we cannot therefore say what might have been accomplished at an ear- 
lier moment, but I confess that our defeat was unexpected, and does not 
seem to me to be satisfactorily explained. 

Results. — At least ten have left no appreciable lameness or deformity, 
and possibly several more. It is therefore probably true that these con- 
sequences may be avoided with proper care in one-half of the examples 
in which we attempt to save the finger ; and perhaps it will occasion 
surprise that a perfect result may not be claimed in a larger proportion ; 
but when we consider how frequently the accident is compound, and that 
even when it is not, the blow having generally been received directly 
upon the point of fracture, how promptly swelling ensues, it will be easily 
understood that it will be often found difficult to determine whether the 
bone is exactly in line or not, or to maintain it in this position after abso- 
lute coaptation has been once secured. 

I have seen the finger in two or three cases deviate laterally, or be- 
come permanently deflected to one side or the other ; and once I have 
found it united, but rotated on its own axis. This latter case is not with- 
out instruction. 

A girl, aet. 6, had her little finger caught by a door violently shut, 
breaking one of the phalanges, and nearly severing the finger. I closed 
the wound, and dressed the finger with a moulded pasteboard splint. My 
dressings were repeated often, and applied carefully ; nor did I detect 
the rotation which the lower fragment had made upon its own axis until 
the union was consummated. I then found the extremity of the finger 
turned so that its palmar surface presented diagonally toward the ring 
finger. 

If the surgeon believes that this ought to have been prevented, and 
that the result evinces a lack of skill or of care, its record may still serve 
one of the purposes for which it was designed, and secure to the patient 
sometimes hereafter more faithful and assiduous attention. 

Treatment. — Boyer, and after him Bransby Cooper, have taught that 
when the extreme phalanx is broken, from the small size of the bone, 
and from its having attached to it the nail and its matrix, it is better in 
all cases to amputate at once, as the process of reparation is in such case 
extremely slow and uncertain. 

Whether in any of the cases treated by myself, or which have been seen 
by me, the fracture involved the last phalanx, I am not now able to say, 
but my impression is that such cases have come under my notice which 
have been successfully treated, and I cannot but regard the rule estab- 
lished by these gentlemen as much too stringent. Examples must, no 
doubt, sometimes occur, in which the fracture is so simple in its charac- 
ter as to render prompt reunion pretty certain ; and even though the 
restoration should prove tedious, this ought scarcely to be regarded as a 
sufficient justification for so serious a mutilation as these surgeons pro- 



372 FRACTURES OF THE FINGERS. 

pose, since the loss of even an extreme phalanx is not only a deformity, 
but must prove in many occupations a troublesome maiming. 

Prof. J. Lizars, of the Toronto school of medicine, C. W., has re- 
ported to me a case exactly in point. "A man in the employ of the 
Toronto Rolling Mills Company fractured the distal extremity of the 
ring finger of the right' hand. The fracture was transverse, and the 
nail was severely bruised, the accident being caused by a direct blow. 
Crepitus distinct. A dorsal splint and bandage were applied, and in a 
short time the fragments were united firmly by bone. The nail subse- 
quently fell off, and a new one was formed." 

The rule ought still to be held inviolate, which surgeons have so often 
repeated in reference to injuries inflicted upon the hand and fingers, 
namely, that we should save always as much as possible. 

It is remarkable, too, how much nature, assisted by art, can do toward 
the accomplishment of this purpose. If the bone of a finger is not only 
severed completely, but also all of its soft coverings, save only a narrow 
band of integument, are torn asunder, a chance remains for its restora- 
tion. And it is especially interesting to observe what recuperative 
powers are possessed by the articular surfaces of these smaller joints, so 
that although they may be broken into, or sawn through, or comminuted, 
and although small fragments be entirely removed, a complete restora- 
tion of their functions is sometimes permitted. I have seen and reported 
some such examples. It is true, however, that such fortunate results 
are rare, and they are rather to be hoped for than anticipated. 

Since, in the case of these delicate bones, the slightest deviation from 
the natural form or position determines in the end an ugly deformity, 

it becomes exceedingly ne- 

Fig. 118. cessary, especially with 

_.-:---!--..._ females, that we should 

,..-"" i. ; / ' "" v *^. open the dressings and ex- 

"'•-.., amine the fingers carefully 

from day to day, so that, as 

the swelling subsides, we 

may discover and correct 

any displacement which 

may happen to exist. 

As a splint, I have found 
Gutta-percha splint for Anger. nothing so convenient as 

gutta-percha, moulded ac- 
curately to either the dorsal or palmar aspect of the finger ; and the 
form of which I have found it generally necessary to change slightly 
every third or fourth day, until consolidation is nearly or quite com 
pleted. 

If the fracture is near or extends into a joint, the finger ought to be 
a little flexed so as to place it in the most useful position in the event 
that anchylosis should occur ; and as early as the end of the second 
week the joint surfaces should be slightly moved upon each other, in 
order to the prevention of fibrous or bony adhesions. Nor is there 
much danger of preventing the union of the bone by moving the joints at 
this early day. Union occurs between these fragments very speedily, 




FRACTURES OF THE PELVIS. 373 

and I have never met with a case of non-union of the phalanges, nor do 
I remember to have seen a case reported. 

It is the lateral inclination of the distal end of the finger which, ac- 
cording to my experience, it will be found most difficult to obviate, and 
which may, perhaps, in some cases be most successfully combated by 
laying the two adjoining sound fingers against the broken finger, and 
then applying a moulded splint to the palmar surface of the whole. In 
other cases it will be more convenient to apply the splint only to the 
broken finger. 

Rotation of the lower fragment on its own axis is especially to be 
guarded against, as the deformity which it occasions is more unseemly, 
and the impairment of utility more decided, than that occasioned by a 
lateral deviation. 

It may be well also to remind the surgeon of the convenience of ex- 
tending the splint beyond the end of the last phalanx, and moulding it 
to this extremity, in order that the finger may be protected against in- 
juries, and that when, from time to time, the splint is removed, it may be 
reapplied with accuracy. 

In all cases the splint should be lined with cotton cloth, soft flannel, 
or patent lint, and secured in place with narrow and neatly cut cotton 
rollers. Bandages of this width should never be torn, but carefully cut 
with scissors. 



CHAPTEE XXVIII. 

FRACTURES OF THE PELVIS, AND TRAUMATIC SEPARATIONS 
OF ITS SYMPHYSES. 

Develop?nent of the Os Innominatum. — This bone is formed from 
eight centres, three of which are called primary, and five secondary. 
The three primary centres belong respectively to the ilium, ischium, 
and pubes, and by their extension form eventually the greater portion 
of the innominatum. They have a common point of union in the ace- 
tabulum ; and the ischium unites with the pubes, also, by the junction of 
their rami. These conjunctions occur usually between the fifteenth and 
twentieth years of life. The secondary centres do not begin to ossify 
until the age of puberty, and may therefore properly be considered as 
epiphyses. One forms the crest of the ilium ; one its anterior inferior 
spinous process ; one forms the symphysis pubis ; one the tuberosity of 
the ischium ; while the fifth constitutes the centre of the bottom of the 
acetabulum. The epiphyses become joined to the primary bones, or the 
bodies of the innominata, at about the twenty -fifth year. 

§ 1. Pubes. 

Lente, in his reports from the New York Hospital, mentions the case 
of a young man, set, 18, who was crushed between a couple of cars, in 



374 



FRACTURES OF THE PELVIS 



consequence of which he died two days after. The autopsy disclosed a 
separation of the symphysis pubis, unaccompanied with any other frac- 
ture. The right side was displaced backwards about half an inch, so 
that the fingers could be passed between the bones. There was also a 
wound in the top of the bladder large enough to admit the thumb. 1 



Fig. 119. 



C-re** 




Tub** 

Development of the os innominatum. (From Gray.) 

Similar accidents have been several times met with by surgeons. Hall 
reports a case in the Provincial Medical and Surgical Journal, May 1, 
1844, in which the pubes, thus separated, was actually thrust into the 
bladder ; but in this example the ilium was broken also. I need 
scarcely add that this patient died ; 2 but Sir Astley Cooper has furnished 
us with an example of a simple fracture or traumatic separation at the 
symphysis, from which the patient after a long time almost completely 
recovered. The following is Sir Astley's account of the case : — 

" Case 79. Richard White, set. 22, was admitted into Guy's Hospital 
on the 30th of July, 1832, having sustained a severe injury in conse- 
quence of a large quantity of gravel having fallen upon his back while 
in the act of stooping. It knocked him down ; and on rising, which 
he did with considerable difficulty, he attempted to walk ; this produced 
violent pain in the region of the bladder, extending upwards in the 



1 Lente, New York Journ. Med., 2d ser., vol. iv. p. 286. 

2 Hall, Amer. Journ. Med. Sci., vol. xxxiv. p. 248. 



pubes. 375 

course of the ureters to the kidneys. Upon inquiry, he stated that 
the urine he had voided since the accident was bloody and passed with 
difficulty. 

" On examination, a fissure was found at the symphysis pubis, pro- 
ducing a separation of about two fingers' breadth. On pressure being 
made upon any part of the ilium, he complained of increased pain in the 
region of the pubes, and of numbness down the left thigh. 

U A catheter was immediately passed, and the urine which was drawn 
off was clear and healthy. Leeches were applied over the pubes, and 
a broad belt was firmly buckled around the pelvis sufficiently tight to 
bring the separated pubes nearly in contact, and the patient ordered to 
be kept perfectly quiet in the recumbent posture, on low diet. The 
leech-bites ulcerated, and some slight degree of fever resulted, which, 
however, readily yielded to the usual treatment. 

" He remained in the hospital for three months without any check to 
the progress of his cure ; the length of time it required being accounted 
for by the difficulty of reparation in the amphiarthrodial articulation ; 
and when he left there was some slight separation of the pubes remain- 
ing ; nor were the two lower extremities, or the anterior and superior 
spinous processes of the ilia, perfectly symmetrical, although he could 
walk very well." 1 

Malgaigne has collected four cases of simple separation at the sym- 
physis pubis occasioned by external violence, and in three of the four 
cases it was occasioned by pressing out the thighs with great force ; the 
separation being directly due, therefore, to muscular action. 

Two of these patients succumbed to the accidents. The same author 
has brought together, also, seventeen cases of separations of this sym- 
physis occurring in childbirth, of which only seven survived. 

It is much more common, however, to find the pubes broken through 
its horizontal or ascending ramus ; and Clark, of the Massachusetts 
General Hospital, has described a case of simultaneous fracture of the 
pubes and ischium in three places. The man, set. 29, had been caught 
between two heavy timbers, and on the following day, May 7, 1852, he 
was brought to the hospital. 

No crepitus could be detected, but he was unable to lie upon the 
right side, and the right limb was nearly paralyzed. It was evident 
that the bladder or urethra had been ruptured, and on the third day 
Dr. Clark opened the bladder through the perineum, evacuating a large 
amount of blood and urine, and affording to the patient very sensible 
relief. On the first of June, however, he died, having survived the 
accident twenty-five days. 

The autopsy disclosed several fractures, all of which belonged to 
the right os innominatum. First, a fracture of the pubes near the 
symphysis ; second, a fracture near the junction of the pubes and 
ilium ; third, a fracture through the ramus of the ischium anterior to 
the tuberosity. 2 

Sir Astley mentions a case (Case 83) of fracture of the " ramus of the 

1 Sir Astley Cooper, Frac. and Disloc, Airier, ed., p. 144. 

2 Clark, Boston Med. and Surg. Journ., vol. liii. p. 185. 



376 



FRACTURES OF THE PELVIS. 



Fig: 120. 




Clark's case of fracture of the pelvis. 



pubes," unaccompanied with injury to the bladder or urethra, which re- 
sulted in a complete recovery ; and in another case (Case 84) the patient 

recovered in eight weeks, and was 
able to walk nearly as well as before ; 
but he soon after died of disease of 
the chest. The os pubis was found, 
at the autopsy, to have been broken 
in three places ; there was also a 
fracture extending in two directions 
through the acetabulum, with an 
extensive comminuted fracture of 
the ilium, accompanied with great 
displacement. 

Marat has even found it neces- 
sary, after a fracture, to remove 
nearly the whole of the body of the 
pubes by incision, in a girl of 18 
years, and who not only recovered 
completely, but having subsequently 
married, she gave birth to two chil- 
dren in easy and natural labors. 1 
Cappelletti relates that a man, set. 54, jumped from a carriage, the 
horses having run away, and alighted with his feet to the ground, but 
with one limb in the greatest possible degree of abduction. A surgeon, 
who saw him immediately, found an enormous swelling at the superior 
part of the thigh, accompanied with very acute pain. When seen by 
Cappelletti, at Trieste, six months after, there still remained a slight 
swelling near the ramus of the ischium and. pubes, under which a careful 
examination detected a fragment of bone two and a half inches long and 
of the " size of the finger." The patient was able to walk, but not 
without pain and limping. Cappelletti soon began to suspect that this 
fragment of bone consisted of a part of the ramus of the ischium and 
pubes detached by muscular contraction. On examining it anteriorly, 
he found this part of the pelvis defective, and the loose portion of the 
bone had all of the anatomical characters of the defective part. He 
felt distinctly the circular projection indicating the point where' the as- 
cending branch of the ischium unites with the descending branch of the 
pubes. 2 

Whitaker, of Lewistown, N. Y., saw the body of the left os pubis 
broken in a female while in the seventh month of pregnancy. She had 
fallen doAvn a pair of stairs, striking astride the edge of an open, upright 
barrel. The fracture was oblique, and with but little displacement ; yet 
she complained of excruciating pain in the left pubic region on the least 
motion. The accident was followed by no positive attempt at miscar- 



' Marat, from Malgaigne, op. cit., p. 646. 

2 Cappelletti, Ranking's Abstract, No. viii. p. 83 ; from Griornale per servire al 



Progressi della Patologie della Terrapeutica, 1847. 
8 Whitaker, Amer. Journ. Med. Sci., July, 1857, p. 283. 



ischium. 377 

The danger in these accidents consists not so much in the fracture, as 
in the injury done to the bladder and other pelvic viscera. If the blad- 
der is opened into the peritoneal cavity, death is almost inevitable ; and 
even when the bladder or urethra has suffered laceration lower clown or 
at any point above the deep perineal fascia, extensive urinary infiltra- 
tions, followed by abscesses and gangrene, generally expose these patients 
to the most imminent hazards. 

The practice pursued at Guy's Hospital, in the case of separation at 
the symphysis pubis, commends itself both by its simplicity and by its 
success. Antiphlogistic remedies steadily pursued, rest in the recum- 
bent posture, the use of the catheter when necessary, and in certain 
cases the girding the pelvis with a firm belt or band, are measures which 
seem to meet all of the important indications. 

If the fracture is accompanied with displacement it will be proper to 
attempt to restore the fragments, but except in the case of separation at 
the symphysis very little aid can be expected from a band or any similar 
means in retaining them in place. It will be sufficient, generally, in 
such examples to place the patient quietly upon his back, with his thighs 
flexed upon his body, and to treat the accident in all other respects as a 
case of inflammation. 

If the urine has become extravasated underneath the pelvic fascia, no 
time ought to be lost in opening freely through the perineum, and in ex- 
tending the incision, if necessary, into the urethra and bladder. 

§ 2. Ischium. 

When speaking of fractures of the pubes, we have already noticed 
some examples of fractures of the ischium also ; indeed it is seldom that 
one of the bones of the innominatum is broken without a coincident frac- 
ture of one or both of the others. The records of surgery furnish several 
other examples, produced generally by a fall upon the tuberosities ; but, 
perhaps, the most remarkable instance is that mentioned by Marat as 
having occurred in a female during her labor. 

The following summary of a case of fracture of the ischium, reported 
by Sir Astley Cooper, will serve to illustrate one of the most fortunate 
terminations of these accidents when accompanied with a rupture of the 
urethra : — 

A young man who was driving a cart w r as thrown down, and a wheel 
passed over him. On the following morning he was found to have a 
fracture of the left leg and a contusion of the inner side of the left thigh. 
There was also great swelling and ecchymosis of the scrotum, with a 
slight appearance of injury over the pubes and left hypochondrium. No 
fracture of the pelvis was at that time discovered. The patient was suffer- 
ing great pain, and was cold and exhausted. Bloody urine escaped from 
the bladder. On the eighth day an abscess had pointed on the left side 
of the perineum, which, being opened, discharged a great quantity of 
pus having the odor of urine ; extensive sloughing occurred, and the 
patient sank very low. On introducing the finger into the wound, the 
ascending ramus of the ischium could be distinctly felt, and the fracture 
traced in an oblique course, the upper fragment being slightly displaced 
25 



378 FRACTUEES OF THE PELVIS. 

forwards. When the catheter was introduced into the urethra it was 
found to enter this wound, and could be felt resting against the naked 
bone. From this time until the twenty-sixth day, the urine continued 
to escape freely through the wound. In about six weeks more the fistu- 
lous opening had entirely closed, and after several months his recovery 
was complete. 1 

The signs of this accident are generally even more obscure than those 
of fractures of the pubes, but in a case of doubt the bones ought not 
only to be carefully examined from without, but the finger should be 
introduced freely into the rectum and the anterior surface explored ; or 
the tuber ischii may be grasped between the thumb and finger and 
moved laterally in order to determine the existence of motion or crepi- 
tus. If the patient is a female, this exploration can be best made 
through the vagina. By flexing and extending the thigh, also, crepitus 
may sometimes be discovered. The examination will generally be made 
while the patient lies upon his back; but if turning is not found too 
painful, it will be well to lay him upon his face, that the tuberosities of 
the ischium may be more plainly brought into view. 

A considerable proportion of the fractures of both the pubes and the 
ischium are accompanied with lesions of the bladder or of the urethra, 
either of which circumstances will render the prognosis very unfavor- 
able ; but in simple fractures recoveries may generally be expected, yet 
only after a tedious confinement. 

It is not usual, except in cases which must almost necessarily prove 
fatal, to find much displacement of the fragments ; nor is it probable 
that by any manoeuvres the slight displacements which are found to 
exist can be entirely overcome. Instances may occur, however, in 
which careful pressure from without, or the introduction of a finger into 
the rectum or vagina, may aid in the restoration. 

The posture best suited to these cases will be indicated usually by 
the sensations of the patient himself. Ordinarily he will prefer to lie 
upon his back with his thighs flexed and supported by pillows; and his 
hips slightly elevated by a firm cushion laid under the upper part of the 
sacrum. His knees ought also to be gently bound together ; but if the 
patient finds this position painful or excessively irksome, as sometimes 
he will, he may be permitted to occupy any position which he finds most 
comfortable. 

§ 3. Ilium. 

Fractures of the ilium are much more common than fractures of 
either the ischium or pubes, and they assume a great variety of forms, 
directions, and degrees of complication. 

In the two following examples the anterior superior spinous process 
alone was broken off: — 

John Kelly, set. 36, admitted to the Hospital of the Sisters of Charity, 
Dec. 28, 1852, having just fallen and broken the anterior superior 
spinous process of the ilium. The fragment was displaced downwards 
about one-quarter of an inch. Motion and crepitus distinct. A slight 

1 Sir A. Cooper, by Bransby Cooper, Amer. eel., p. 140. 



ilium. 379 

ecchymosis existed over the point of fracture, and other signs of contu- 
sion about the hip were present. He was intoxicated at the time of the 
accident, and could not tell how or where he fell. 

He was laid upon his back in bed, with his thighs flexed upon his 
body ; and in this position we attempted to reduce the fragment and 
retain it in place with a bandage, but finding this impossible, we left him 
with only instructions to remain quietly in bed. In about two weeks 
the fragment was firmly fixed in its new position, and he was allowed to 
get up and walk about, which he was able to do without inconvenience. 

July 13, 1853, Matthias Morrison was caught under a bank of falling 
earth, and on the following day Dr. Mixer, his attending surgeon, re- 
quested me to see the case with him. He was unable to stand upon his 
feet. There was a lacerated wound and an extensive bruise on his. left 
hip ; but the thigh was not shortened nor everted, and he could flex it 
slightly upon his body. Noticing a swelling and discoloration in the 
region of the anterior superior spinous process of the ilium, I pressed 
upon it and felt it recede with a distinct crepitus ; the fragment, how- 
ever, immediately resumed its place when the pressure was removed. I 
was able also, by a careful manipulation, to trace the line of fracture, 
and to determine that it included a small portion of the anterior ex- 
tremity and wing of the pelvis. 

We directed the patient to remain quietly upon his bed with his legs 
drawn up. He soon recovered, but I am unable to say what is the 
present position of the fragment. 

In the case of Mooney, aet. 50, admitted to Bellevue, September 10, 
1871, the fragment was displaced downwards one inch, and could not, 
by flexion of the limb, be replaced. It was not united at the end of 
three weeks. The ability to move his limb was unimpaired. 

More frequently, however, the fracture involves a still larger portion 
of the crest, as in the following examples : — 

Joseph Joquoy, set. 40, was caught by the bumpers between two 
cars, Feb. 10, 1851, breaking obliquely the anterior superior portion of 
the ilium. I saw him within an hour, and found him greatly prostrated ; 
the fragment of the pelvis broken off was quite movable, and crepitus 
was easily detected. His abdomen was very tender and slightly 
bloated. 

He was laid upon his back with his legs drawn up, and hot fomenta- 
tions of hops and vinegar were directed to be applied to his belly. He 
also took one grain of morphine. The broken ala did not seem dis- 
posed to become displaced. With no other treatment, his recovery was 
rapid ; and the bones seemed to have united without displacement. 

James Roche, ?et. 11, fell March 7, 1851, from a height of fourteen 
feet, breaking off the anterior superior portion of the right ala of the 
pelvis. On the following day, I found him at the hospital of the Sisters 
of Charity. The fragment, which was quite large, was movable, and 
occasionally a crepitus could be detected. It was displaced downwards 
and forwards about three-quarters of an inch. 

He was laid upon his back, with his thighs and legs moderately 
flexed. At the end of two weeks he found himself able to walk without 
much difficulty, and he immediately left the hospital. At this time the 



380 FRACTUEES OF THE PELVIS. 

fragment was displaced in the same manner and direction as at first, but 
I cannot say whether it had united or not. 

I have three other similar cases upon my records; but in the last 
example, the sixth, which has been especially recorded, the fracture 
was caused by the muscular action. William Alexander, set. 70, on the 
5th of September, 1869, after riding in a railroad car about half an 
hour, arose to leave his seat, when he felt "something wrong" in his 
right groin, and found himself unable to walk without great pain. He 
was admitted to Belle vue Hospital on the same day, and I found a 
fracture involving about three inches of the ilium, including the anterior 
superior spinous process. It was inclined to fall outwards, but was 
easily replaced with a distinct crepitus. 

I have once seen a fracture of the posterior superior spinous process, 
and I do not know of any other example. 

Miss B., get. 19, was thrown from her horse backwards, striking with 
her back upon the ground. She was first attended by Dr. Conn, of Ovid, 
N. Y., and she did not come under my care until two weeks after the 
accident. 

I found a small fragment broken from the posterior superior spinous 
process of the ilium, and displaced backwards in the direction of the 
spine about half an inch. It was movable, and by pressure it could be 
partially restored to place, but it would immediately return to its abnor- 
mal position when the pressure was removed. The injured hip was 
painful, and occasionally it felt numb. She had previously suffered 
from spinal irritation. 

I laid a compress behind the fragment, and secured it in place with a 
roller, enjoining perfect rest. She recovered from her lameness in a 
few weeks, but I believe the fragment remains displaced. 

Extensive comminuted fractures of the ilium are generally accompa- 
nied with so much injury of the pelvic viscera as to prove rapidly fatal ; 
but the following example will show that this rule admits of exceptions. 

June 5, 1854, Bernard Duffie, set. 32, was crushed under a very heavy 
stone which fell upon his back. I found the left ala of the pelvis broken 
into several fragments, between the different portions of which motion 
and crepitus were distinct. The fractures were near the superior part 
of the bone, commencing about two inches back of the anterior superior 
spinous process, and extending backwards irregularly. There was a 
narrow wound communicating with the fracture, from which I removed 
a loose fragment of bone. The right leg was also broken. 

Four months after, he was still confined to his bed, and a fistulous 
opening continued opposite the point of fracture ; there existed also a 
large and irregular mass of ossific matter or callus around the fragments. 
He soon after left the hospital. 

Dr. Sargent, of the Massachusetts General Hospital, has reported a 
case in which a man received a compound fracture of the left ilium, and 
several small fragments were removed. He was discharged at the end 
of three months with a fistulous opening still remaining, but in other 
respects he was quite well. 1 Dr. Cheever, of the same hospital, reports 



Sargent, Boston Med. and Surg. Joura., vol. liii. p. 121. 



ilium. 381 

a case of fracture of the ilium, with fracture of the ascending ramus of 
the pubes, resulting in complete recovery ; but the leg became shortened 
and the toes inverted. Dr. Cheever believes that the lines of fracture 
met in the acetabulum. 1 

The following case illustrates the more fatal injuries of this char- 
acter : — 

John O'Keaf was crushed under a heavy stone, Oct. 23, 1851, break- 
ing and comminuting the alse of the pelvis on both sides, and wounding 
also the iliac vein. He was taken to the hospital of the Sisters of 
Charity, and died in a few hours, partly from the shock to his system, 
and partly from the hemorrhage. 

Lente, of the New York Hospital, has reported a case of dislocation 
of the hip, which was accompanied with a fracture also of the ala of the 
pelvis upon the same side. The dislocation was reduced on the third 
day, and the patient soon after died. The autopsy disclosed what had 
not been suspected during life, namely, that the left ilium was broken 
horizontally about through its middle, and vertically through the crest; 
and also that there was a fracture extending through the sacro-iliac syn- 
chondrosis, accompanied with considerable comminution of the articular 
surfaces. It was also found that a portion of the small intestine was 
ruptured, and probably by one of the sharp fragments of the broken 
pelvis. 2 

It is seldom, I think, that the fragments become much displaced ; such, 
at least, has been my experience ; and I have noticed in Dr. Neill's 
cabinet three specimens of fracture of the crest of the ilium, all of which 
had united without any appreciable displacement. DreNeill also called 
my attention to the fact that in two of these specimens the ensheathing 
callus was confined to the outer surface of the bone ; an observation 
which, this gentleman assures me, he has had frequent occasion to make 
before where the fracture belonged to a flat bone. 

If any displacement exists, the upper or loose fragment is generally 
carried slightly inwards ; occasionally, however, it is found displaced 
upwards, outwards, or downwards. 

Treatment. — In a large majority of cases the fragments, if displaced, 
cannot be completely replaced. Occasionally, however, as where the 
anterior superior spinous process is broken off with only a small portion 
of the crest, the fragment may be seized with the fingers and carried 
outwards or upwards, or in whatever direction may be necessary ; but 
to retain it in this position is generally quite impossible. The bandage 
or broad belt which we have recommended in certain fractures of the 
pubes would be in these cases not only useless, but absolutely mischiev- 
ous, since its effect must be to press inwards the fragments, and thus to 
create a displacement which might not otherwise exist. 

The surgeon ought to determine by a careful examination the extent 
and direction of the fracture, and, having done what was in his power to 
replace the fragments, he should lay his patient upon his back with the 
thighs drawn up and supported. This is the position which will gener- 

1 Cheever, Bost. Med. and Surg. Journ., May 3, 1866. 

2 Lente, New York Journ. of Med., Jan. 1851, p. 29. 



382 FKACTUKES OF THE PELVIS. 

ally be found most comfortable ; but, as in other fractures of the pelvis, 
it may be well always to try the effect of other positions, and especially 
to determine their influence upon the fragments, and finally to adopt 
that precise posture which accomplishes the indications best. 

If the fracture is compound, and the fragments have penetrated the 
belly, the w^ound should be enlarged, and, as far as possible, every piece 
of bone should be removed ; but if the fragments cannot be found, the 
external opening should be allowed to remain so as to favor their escape 
when suppuration shall have taken place. 

§ 4. Acetabulum. 

Although, strictly speaking, fractures of the acetabulum belong 
always to one or all of those bones of the pelvis whose lesions have 
already been described, yet the peculiar relations of this cavity to the 
femur render it necessary that they should be considered as a separate 
class of accidents. 

Fractures of the acetabulum divide themselves naturally into two 
varieties. 

First. Fractures of the base of the cavity, with or without displace- 
ment. 

Second. Fractures of the rim, with or without displacement. 

In fractures of the base of the cavity, not accompanied with displace- 
ment, nothing but crepitus can be present as a sign of the accident ; and 
this will scarcely be sufficient, in itself, to enable the surgeon to distin- 
guish it from a fracture of the neck of the femur within the capsule with- 
out displacement. 

It is probable, therefore, that its existence will only be determined 
by dissection. Nor is it of much importance that the diagnosis should 
be made out ; since in either case neither splints nor any other surgical ap- 
pliances could be of service. An injury so severe as to fracture the ace- 
tabulum will necessarily so much bruise the body, and concuss the viscera 
of the pelvis, as to compel the patient to remain quiet for a number of 
days, and this is all that would be thought necessary if the nature of 
the accident was exactly determined. 

Dr. NeilPs cabinet contains a specimen of this kind, in which the frac- 
ture, commencing near the centre, extends in three directions across the 
cotyloid margins, in which perfect bony union has occurred without dis- 
placement. 

M. Bouvier related to the Academy the case of a man, set. 71, who, 
in consequence of a fall from his bed, remained for three weeks unable 
to walk, and never was able afterwards to walk without crutches. No 
fracture could be discovered during life, but after his death, which oc- 
curred some months subsequent to the accident, a fracture was found 
extending from the ilio-pectineal eminence to the spine of the ischium, 
and traversing the centre of the acetabulum. The fragments were not 
displaced, but remained slightly movable. 1 

1 Bouvier, Amer. Journ. Med. Sci., vol. xxiii. p. 486; from Bullet, de l'Acad. Roy. 
de Med., August 15, 1838. 



ACETABULUM. 383 

The following case was reported by Mr. Earle, to the London Medico- 
Chirurgical Society, and will be found in the nineteenth volume of its 
Transactions. It is also referred to by Sir Astley, in his Treatise on 
Fractures and Dislocations: — 

In the month of October, 1829, a man, set. 40, was admitted into St. 
Bartholomew's Hospital, with a severe injury, caused by having fallen 
from a height of thirty-one feet, and striking upon the left side. The 
left leg was powerless and shortened. The foot was everted. Any at- 
tempt to rotate the limb caused great pain, and was accompanied with a 
sensible crepitus. The left trochanter was very much depressed, and 
when it was pressed upon, the patient complained of deep seated pain 
in the hip-joint. 

He recovered in eight weeks, and was able to walk nearly as well as 
before ; but he soon after died of disease in the chest. 

On dissection, a fracture was found extending in two directions through 
the acetabulum ; there was an extensive comminuted fracture of the 
ilium, with great displacement, and the os pubis was broken in three 
places. 

The repair was very complete, and Mr. Earle remarked how nature 
had guarded against any considerable deposit of new bone within the 
articulation, which might have interfered with the functions of the joint, 
while there was an abundant deposit of callus around the other parts of 
the fractured bone. 

Mr. Travers has reported two similar cases, and in the paper accom- 
panying the report he maintains that very acute pain caused by pressing 
upon the projecting spine of the os pubis, and the inability of the patient 
to maintain the erect posture, may be regarded as signs diagnostic of the 
accident. 1 It is doubtful, however, whether these phenomena, so com- 
mon to many other accidents, could be relied upon as evidence of this 
peculiar lesion. 

Fractures of the base of the acetabulum, with displacement of the 
femur into the pelvic cavity, constitute a much more formidable, and un- 
fortunately a more common form of accident. 

Like the preceding variety of acetabular fractures, they are produced 
generally by falls upon the trochanter major, but the force of the con- 
cussion has been greater. 

Even here, it is not often that the diagnosis has been clearly made out 
during life ; and indeed, generally, the true character of the accident 
has not even been suspected, the surgeons believing that they had to do 
with a fracture of the neck of the femur, or with a dislocation. In two 
examples (Cases 71 and 72) mentioned by Sir Astley Cooper as having 
been presented at St. Thomas's Hospital, the thigh was thought to be 
dislocated backwards. 

In the following example reported by Lenclrick, of Dublin, the patient 
was supposed to have a fracture of the neck of the femur: — 

An old man, well known as the "Wandering Piper," was admitted 
into the Mercer Hospital in January, 1839, suffering under phthisis pul- 
monalis and acute inflammation of the hip-joint. Some years before, he 

1 Travers, Holmes's System of Surgery, vol. ii. p. 478. 



384 FRACTURES OF THE PELVIS, 

had received a severe injury by the upsetting of a coach, and was under 
treatment several months for what was supposed to be a fracture of the 
neck of the femur. Since that time he had been lame, but still able to 
take a great deal of exercise on foot both in Great Britain and in Amer- 
ica. The acute disease of the joint commenced about two months before 
his admission, and he was at first under the care of Sir Philip Crampton, 
who remarked that the thigh was only shortened about half an inch, and 
expressed his surprise at this fact. 

This man died on the 17th of February, and the dissection showed 
that there had been no fracture of the femur, but its head and neck 
were affected with " morbus coxae senilis." The head was also thrust 
through a rent in the acetabulum into the cavity of the pelvis ; but the 
head had again been covered by a bony case, complete, except in a 
small portion about the size of a shilling piece, and at this point the 
covering was ligamentous. 

The os pubis had also been broken at the same time, and it had 
united so much overlapped that the space between the inferior anterior 
spinous process and the symphysis pubis was shortened nearly an inch. 
A portion of intestine was found protruding through an opening in the 
pelvis and adherent to the bone, in which situation it seemed to have 
been caught by the broken fragments and retained. 1 

Morel-Lavallee, in his thesis upon complicated luxations, mentions a 
case which had come under his observation, and which had been treated 
as a fracture of the neck of the femur. The patient survived the acci- 
dent many years ; during a part of which time he suffered such pain in 
the hip-joint as to induce a belief that it was itself diseased. At his 
death he was found to have had a multiple fracture of the bones of the 
pelvis, and the head of the femur had penetrated more than an inch into 
the cavity of the pelvis, pressing upon the obturator nerve to such a 
degree as to have, no doubt, caused the severe pain from which he had 
suffered, and which had been ascribed to coxalgia. 2 

In the two cases mentioned by Sir Astley Cooper as having been re- 
ceived into St. Thomas's Hospital, the toes were turned in. In the 
example mentioned by the same author as having been presented at St. 
Bartholomew's Hospital, the toes were everted ; the two persons seen 
by Lendrick and Morel-Lavallee were supposed before death to have 
had a fracture of the neck : it is probable, therefore, that in both of 
these cases the toes were also everted ; while Moore has dissected a 
subject whose pelvis was broken into many fragments — the left os in- 
nominatum was divided into three portions, corresponding to the three 
bones of which it was composed in infancy ; the head of the femur had 
completely penetrated the basin ; the limb was shortened two inches, 
and in a position of slight flexion and adduction, but neither rotated 
outwards nor inwards. 3 

There seems, therefore, to be no certain rule in relation to the posi- 
tion of the limb ; but it is found to take the one position or the other, 

1 Lendrick, Amer. Journ. Med. Sci., vol. xxiv. p. 481 ; August, 1839 ; from London 
Med. Gazette, March, 1839. 

2 Morel-Lavallee, from Malgaigne, op. cit., vol. ii. p. 881. 

3 Moore, Med.-Chir. Trans., vol. xxxiv. p. 107, 1851. 



BASE OF THE ACETABULUM. 385 

probably according to the direction of the force which has inflicted the 
injury, and perhaps in obedience to circumstances not always easily ex- 
plained. 

The shortening has been observed to vary from half an inch to two 
inches or more ; the trochanter is also usually driven in toward the 
pelvis. Pressure upon the trochanter occasions a deep-seated pain. If 
the limb is drawn down to the same length with the other, it immedi- 
ately resumes its position when the extension is discontinued. Crepitus 
is more uniformly present than in fractures of the neck of the femur, 
and it is especially felt while the limb is being extended or while it is 
again shortening, and not so much in flexion or rotation. 

If, in addition to all of these phenomena, we learn that the accident 
has occurred from a severe blow, or a fall from a great height upon the 
trochanter ; and that the viscera of the pelvis, and especially the bladder, 
seem to have suffered considerable injury ; or if we detect at the same 
time a fracture of some other portion of the pelvis — we may reasonably 
conclude that the head of the femur has penetrated the acetabulum. 
Yet it must be confessed that no one of these symptoms is positively 
distinctive of this accident, and that they are seldom found sufficiently 
grouped to render the diagnosis certain. 

The old " piper" mentioned by Lendrick, and the man dissected by 
Morel-Lavalle'e, lived many years, and managed to walk about, but not 
without considerable pain ; the other three, to whom I have alluded, 
died soon after the injuries were received. 

Some have thought of treating these cases by extension and counter- 
extension ; the latter being accomplished through the aid of a perineal 
band ; but it is not probable that after an injury of this character, any 
patient will be able to endure the requisite pressure about the perineum 
or groins. It will be better to lay the patient upon Daniel's invalid 
bed, or some bed similarly constructed, so that it may be converted into 
a double-inclined plane ; allowing the knees to be suspended over the 
angle thus formed, in order that the weight of the body may have some 
effect to draw away the pelvis from the femur. Or we may adopt ex- 
tension without the perineal band, as will be described hereafter when 
treating of fractures of the femur; or we may resort to Hodgen's sus- 
pension apparatus. 

Fractures of the rim of the acetabulum have frequently been discov- 
ered in dissections ; and the records of surgery abound with cases of 
unreduced dislocations of the femur, in which the failure to reduce or to 
retain the bone in place has been ascribed, not always with sufficient 
reason, perhaps, to this fracture. 

Dr. McTyer, of the Glasgow Royal Infirmary, published, in the Grlas- 
goiv Medical Journal for February, 1830, four cases of this fracture. 

The first was that of a man, aet. 27, on whose back a number of 
bricks had fallen while he had his right knee placed on the bank of a 
trench. His right leg was found shortened about one inch and a half, 
bent, and the toes turned a little outwards. The limb could be moved 
without much difficulty, but every motion gave him pain ; motion was 
also attended with crepitus. On making extension, the limb was easily 
brought to the same length with the other, but it became shortened 
again immediately when the extension was discontinued. 



386 FRACTURES OF THE PELVIS. 

The symptoms, differing but little, if at all, from those which are 
usually present in a case of fracture of the neck of the femur, led to 
the supposition that this was actually the nature of the accident. Sub- 
sequently, the toes became slightly turned in, but this circumstance 
was not regarded as sufficiently distinctive to warrant a change in the 
diagnosis. 

Having succumbed to the injuries after a few days, the autopsy re- 
vealed a fracture extending through the bottom of the right acetabulum, 
and about one inch and a half of the rim at its upper and posterior 
margin completely detached, except as it was held in place by a portion 
of the capsular ligament. The head of the bone could be easily pushed 
upwards and backwards upon the dorsum, the fragment of the acetab- 
ular margin being moved aside, and swinging upon its fibrous attach- 
ment as upon a hinge, but resuming its place again perfectly when the 
head of the femur was restored to the socket. The femur was not 
broken. 

In the second case the limb was found shortened, the knee slightly 
bent, and turned a little forwards and inwards, and the toes pointing to 
the tarsus of the other foot. It was thought to be a fracture also of the 
neck of the femur, but the autopsy disclosed only a fracture of the upper 
margin of the rim of the acetabulum. 

In the third case, seen only after death, the limb was not shortened 
much, but the toes were stretched downwards, and turned slightly in- 
wards. It was supposed at first to be a simple dislocation, but on dis- 
section the posterior and inferior margin of the acetabulum was found 
to be broken and displaced toward the coccyx, while the head of the 
femur rested upon the pyriformis muscle, over the ischiatic notch. 

The fourth example was found in the dissecting-room, and the history 
of the case is not known. A fragment of the superior and posterior 
margin of the acetabulum had been broken off, and had reunited slightly 
displaced. 1 

Several other similar examples have been established by dissection, 2 
and we are able, therefore, to determine pretty accurately what are the 
usual phenomena and terminations of this accident, though we are far 
from having arrived at a satisfactory means of diagnosis ; indeed, the 
accident has seldom been recognized before death. Its causes are gen- 
erally the same with those which produce dislocations of the hip, but 
in most instances the violence has been greater than in the case of dis- 
locations. 

The symptoms are, first, such as indicate a dislocation, to which must 
be added crepitus and a difficulty, if not impossibility, of retaining the 
head of the femur in its place when it is reduced. The crepitus is 
sometimes discovered the moment we begin to move the limb, and this 
will aid us to distinguish it from a fracture of the neck of the femur 
accompanied with much displacement, since, in the latter case, crepitus 

1 McTyer, Amer. Journ. Med. Sci., vol. viii. p. 517, Aug. 1831. 

2 Maisonneuve, Chirurg. Clin., 1863, p. 168. Sir Astley Cooper on Disloc. and 
Frac, 1823, second London edition, p. 15. M. Beraud, Bulletin de la Soc. de Chir., 
1862, torn. iii. p. 185. Ibid., p. 226. Bigelow on Hip-Joint, 1869, p. 139 et seq. 



KIM OF THE ACETABULUM. ' 887 

is not felt usually until the extension is complete, and the fragments are 
again brought into apposition. 

The majority of these accidents, either from a failure to recognize 
them, or from the impossibility of maintaining the head of the femur in 
place when once it has been reduced, have resulted in a permanent dis- 
location of the hip and a serious maiming. The following case was 
recognized and reduced, but it was found impossible to maintain the 
reduction. 

February 3, 1847, a strong German laborer was crushed under a mass 
of iron weighing several tons. Drs. Sprague and Loomis, of Buffalo, 
were called, and found the left thigh dislocated upwards and backwards, 
and by the aid of six men they succeeded in reducing it, the reduction 
being attended, as the gentlemen informed me, with a slight sensa- 
tion of crepitus. The legs were then laid beside each other, and the 
knees tied together, the patient lying on his back ; and now the two 
limbs appeared to be of the same length. On the second and third days 
the injured limb was examined by the same gentlemen, and there was 
no displacement. On the fourth day I was invited to meet these gentle- 
men, the patient having had muscular spasms during the previous night, 
and the thigh being reluxated. I found the limb shortened one inch and 
a half, adclucted and the toes turned in. We immediately applied the 
pulleys, and soon drew the trochanter down to a point apparently oppo- 
site the acetabulum, and a careful measurement showed that the two 
limbs were of the same length. The pulleys being removed, the leg 
did not draw up again, nor did the foot turn in, yet we had felt no sen- 
sation to indicate that the bone had slipped into its socket, nor had we 
felt crepitus. The legs and thighs were now laid over a double-inclined 
plane, and well secured. He remained in this condition three days 
more, during which time Dr. Sprague saw him each day, and found 
nothing disarranged. On the night of the seventh day the spasms 
returned, and in the morning the thigh was displaced. 

The next day we again applied the pulleys, bat soon found that the 
bone would not remain in place one minute after the pulleys were re- 
moved. 

At this time, while moderate extension was being made at the foot by 
rotating the foot inwards, we could distinctly feel a slight crepitus. A 
straight splint was applied, and as much extension made as he could 
conveniently bear, and in this condition the limb was kept several weeks. 
Seven years after, I found the thigh still displaced upon the dorsum 
ilii. He limped badly, but he could walk fast, and perform as much 
labor as before the accident. 

In one case mentioned by Mr. Keate, the bone had become dislocated 
downwards, and could be felt lying against the tuber ischii, and the 
presence of a " distinct grating as of ruptured cartilage" led him to con- 
clude that the cartilaginous labrum of the socket was broken off; but 
as the fracture was in the lower margin of the socket, no difficulty was 
experienced in retaining the bone in position. 1 

Dr. Homer 0. Hitchcock, of Kalamazoo, Mich., reported to the 

1 Keate, Ainer. Journ. of Med. ScL, vol. xvi. p. 225. 



388 



FRACTURES OF THE PELVIS 



Michigan Medical Society, June 12, 1879, a case of supposed fracture 
of the rim of the acetabulum, accompanied with a backward dislocation, 
which was successfully reduced and retained in place seven or eight 
weeks after the. accident, by Dr. Noyes of Detroit. The surgeons who 
had charge of the patient at first were prosecuted, and a judgment was 
obtained for damages, but this was finally reversed and the surgeons 
fully exonerated. As to what was the precise nature of the case the 
surgeons who testified were not agreed, and perhaps nothing but an 
autopsy could determine. 

Dr. H. 0. Walker, of Detroit, Michigan, presented to the Detroit 
Academy of Medicine, May 27, 1879, a specimen of this fracture, the 
history of which was as follows : A man, set. 78, falling upon his hands 
and knees, was struck on the lower portion of his back by a passing 
street car. He was taken to a hospital, and was found to have a disloca- 
tion upon the dorsum ilii. Reduction was readily accomplished, and 
crepitus was recognized, but its seat not fully determined. The patient 
died in a few hours from shock. In the autopsy the head of the femur 

was found in the socket, but it was 
F IG - 1'21. easily displaced. The ligamentam 

teres and a greater part of the pos- 
terior half of the capsular ligament 
was torn away, leaving a part of the 
anterior portion, together with the 
ilio-femoral ligament, untorn. Some 
of the gluteal muscles were torn 
from their femoral attachments. The 
greater portion of the posterior lip 
of the acetabulum was torn away, 
making an opening through which 
the head of the femur had escaped, 
passing between the fasciculi of the 
ilio-femoral ligament, and resting 
finally near the crest of the ilium. 
Less than one-third of the normal 
depth of the acetabulum remained 
to support the head of the femur 
when it was in place. 1 Dr. Walker 
incidentally mentions that Brodie reported a case which he supposed to 
be of this nature, in the London Lancet, in 1833. 

If the diagnosis is satisfactorily made out, and upon complete reduc- 
tion the femur will not remain in place, the treatment ought to be the 
same as for a fracture of the thigh, except that no lateral splints or 
bandages to the thigh will be necessary. The limb ought to be kept 
drawn out to its proper length, as far as this shall be found to be prac- 
ticable, by extending and counter-extending apparatus. A band around 
the pelvis, so adjusted as to press the head of the bone into its socket, 
may also be of service in preventing the tendency to displacement ; and 
in case the bone manifests little or none of this tendency, the hip band- 




Walker's case of fracture of the acetabulum. 



1 Wcilker, Detroit Lancet, July, 1879. 



SACRUM. 389 

age will probably alone be sufficient, yet even here no harm could come 
of applying the long straight splint and the extending apparatus, secured 
moderately tight, simply as a measure of precaution. Dr. Bigelow 
recommends angular extension, effected by means of an angular splint, 
such for example as Nathan R. Smith's, or Hodgen's, suspended from 
the ceiling, or from some other point above the patient ; " or," he adds, 
" if any manoeuvre has reduced the bone, the limb should be retained, 
if possible, in the attitude which completed the manoeuvre." 

§ 5. Sacrum. 

Simple fractures of the sacrum, known to be exceedingly rare, 1 are 
occasioned either by such injuries as break at the same time the other 
bcnes of the pelvis, or by blows or falls received directly upon the sacrum. 
It may be broken at any point, and in any direction, when the fracture 
is produced by the first of this class of causes ; but if the fracture is the 
result of a fall upon the sacrum, it will generally be transverse, and be- 
low the sacro-iliac symphysis. The displacement in this latter class of 
cases is almost invariably the same, the coccygeal extremity being sim- 
ply carried forwards, yet this is seldom sufficient to interfere in any de- 
gree with the functions of the rectum and anus ; but in one case seen by 
Bermond it nearly closed the rectum. Sometimes, also, there is a slight 
lateral deviation. There is also in the Dupuytren museum, at Paris, a 
specimen in which the whole of the lower fragment is displaced a little 
forwards. 

The signs of this fracture are pain at the seat of injury, aggravated 
greatly in the attempts to flex or elevate the body, and especially in the 
efforts at defecation ; swelling and discoloration of the soft parts cover- 
ing the sacrum ; displacement of the coccyx forwards ; an angular pro- 
jection at the point of fracture, with a corresponding retiring angle upon 
the opposite side ; mobility. 

Experience has shown that where the fracture of the sacrum is accom- 
panied with other fractures of the pelvis, the patients seldom recover ; 
and only because so extensive an injury implies usually great force in 
the cause which produced the fractures, and, of necessity, greater lesions 
among the pelvic viscera. Simple fractures, from falls upon the sacrum, 
occurring below the sacro-iliac symphysis, are generally followed by 
speedy recoveries, although the inward displacement is not often com- 
pletely overcome. 

By introducing a finger into the rectum, the lower fragment can be 
easily pressed back to its natural position, but the difficulty consists in 
finding any means of retaining it there until bony union is effected. 
Judes succeeded to his satisfaction with a wooden cylinder, which he 
compelled the patient to wear forty-five days ; removing it, however, 
every third day, in order to cleanse the rectum with an enema. Ber- 
mond introduced first a linen bag, which he immediately proceeded to fill 
with lint ; but during the night it became necessary to remove it, in order 

1 Malgaigne lias referred to eight cases ; and I have not been able to find a record 
of any others. 



390 FRACTURES OF THE PELVIS. 

to relieve the bowels of wind and stercoraceous matter. He now sub- 
stituted a silver canula covered with a shirt, which latter he filled with 
lint in the same manner as before. This was retained without much in- 
convenience nineteen days ; having only been removed once during this 
time. The union now seemed to be firm, and the apparatus was removed. 
Plugging the rectum in this manner may be necessary whenever the in- 
ward inclination of the lower fragment is found to be considerable, but 
not otherwise ; ordinarily it will be sufficient to lay the patient upon his 
back, with a firm cushion above the point of fracture, so as to prevent 
the bed from pressing in the lower fragment ; and having emptied his 
rectum thoroughly by an enema of warm water, he should be placed 
under the influence of an opiate sufficiently to restrain the action of the 
bowels for several clays, or for as long a time as may be consistent with 
health or comfort. To the same end, also, the diet ought to be light and 
dry ; nothing should be allowed which might prove laxative. By con- 
stipating the bowels, two ends may be gained. We shall prevent that 
frequent action of the sphincters, which might tend to disturb the union ; 
and the hardened faeces, by their accumulation in the rectum, may serve 
to press back the lower fragment of the sacrum, in a manner much more 
natural and quite as effective as any apparatus which can be contrived. 

I have already mentioned a case of separation of the bones at the 
sacro-iliac symphysis, reported by Lente, but which was accompanied 
also with a fracture of the ilium and a dislocation of the hip. Several 
other similar examples have been reported, in some of w T hich both of the 
sacro-iliac symphyses have been separated, or displaced. Such accidents 
are the results only of great violence, and the subjects of them seldom 
recover. 

Dr. J. T. Banks, of Griffin, Ga.,has reported one example of complete 
recovery in an adult male, in which the right sacro-iliac symphysis was 
separated " by a blow received upon the tuberosity of the ischium, driv- 
ing the ilium up an inch or more, causing complete paralysis and anaes- 
thesia of the right leg for two or three weeks ;" motion of the hip caused 
also severe pain. No attempt was made to reduce the bones, but union 
occurred, and he gradually regained the use of his limb. 1 In a few in- 
stances this articulation has been known to give way during labor, while 
the symphysis pubis has suffered little or no diastasis ; and in these cases 
recovery has generally taken place. 

In nearly all the traumatic examples reported, the diastasis has been 
accompanied with a fracture extending parallel with the margins of the 
synchondrosis ; and it is for this reason that I have preferred to con- 
sider these accidents as fractures, rather than as dislocations. 

§ 6. Coccyx. 

The bones which compose the coccyx, four in number, develop slowly, 
the third not presenting an ossific nucleus until from the tenth to the 
fifteenth years of life, and the fourth not until between the fifteenth and 
twentieth year. Subsequently the first and second become united into 

1 Banks, Atlanta Med. and Surg. Journ., May, 1866. 



coccyx. 391 

one, and later the third and fourth are united into one; finally the 
second and third unite, and the coccyx is complete as a single bone. At 
a late period of life, later in the female than in the male, the coccyx is 
united by bone to the sacrum. These facts render it apparent that a 
true fracture can scarcely occur until late in life ; and it seems probable, 
also, that a diastasis or dislocation will be very unlikely to occur. For 
myself, I have never met with the accident in any of its forms. Mal- 
gaigne says he has seen one example of fracture in an autopsy, in which 
case there was also a fracture of the sacrum ; and he adds that Cloquet 
has seen another in an old man, caused by a kick. 

In case a fracture were to occur, the treatment would be the same as 
that already described for a fracture of the lower portion of the sacrum. 

Dr. Geo. A. Mursick, of Nyack, New York, reports 1 two cases of 
" coccygodynia," in which he practised excision of the last two bones 
of the coccyx successfully. One of them was a case of fracture, with 
forward displacement, in a woman twenty -nine years old, and was caused 
by a fall upon the nates. Fourteen months after the accident she came 
under Dr. Mursick' s observation. She was suffering great pain in the 
pelvic region, and especially in the region of the rectum, which was 
aggravated by walking, defecation, and by rising from the sitting 
position. 

June 2, 1873, Dr. Mursick removed the last two bones of the coccyx, 
the patient being under the influence of ether, by making an incision 
posteriorly of two inches in length, exposing the bone thoroughly, and 
then having seized the bone with a pair of forceps, it was drawn out and 
carefully dissected from its attachments. Severe pains in the pelvic 
region followed the operation, with retention of urine, and the -wound 
healed slowly. 

As a result of his two operations he concludes that the operation is 
simple and easy of performance, but that the constitutional disturbance 
which ensues is out of all proportion to its magnitude. The subsequent 
pain is very severe, and lasts for several days ; and the wound heals 
slowly. 

I am also indebted to Dr. Mursick for the statement, that extirpation 
of the coccyx has been practised occasionally since the first differentia- 
tion of coccygodynia by Nott and Simpson, with successful results, but 
especially in those cases which were of traumatic origin. In other 
cases, unaccompanied with fracture or dislocation, subcutaneous incision 
of the attachments of the coccyx has proved sufficient, while in many 
cases, of purely neurotic origin, the cure has, after a time, been effected 
without resort to surgical interference. My own experience confirms 
this latter statement. Nor can I fully appreciate the necessity or ad- 
vantage of resection in any case of simple fracture or diastasis of this 
bone. In the case related by Mursick there is no evidence furnished 
that union had ever taken place between the second and third portions, 
and the age permits a presumption that it had not, and that it was not 
therefore in reality a fracture ; but even if it had been, what possible 
harm could come of its being rendered movable by the fracture, since if 

1 Amer. Jouru. Med. Sci., Jan. 1876, p. 122. 



392 



FRACTURES OF THE FEMUR. 



it were movable it could not interfere with defecation? The coccyx is 
not without its function, and cannot without injury be lost, inasmuch as it 
serves for the attachment of muscles and ligaments, most of which are 
of importance in connection with defecation, and occlusion of the rectum. 



CHAPTEE XXIX. 



FRACTURES OF THE FEMUR. 



Fig. 122. 



Development of Femur. — The femur is formed from five centres of 
ossification: namely, one for the shaft, commencing at about the fifth 
week of foetal life ; one for the lower end, including 
the condyles, commencing at the ninth month of foetal 
life ; one for the head, commencing at the end of the 
first year after birth ; one for the great trochanter, 
commencing during the fourth year; and one for the 
lesser trochanter, commencing between the thirteenth 
and fourteenth years. None of these epiphyses are 
joined to the shaft until after puberty, but consolida- 
tion is generally completed at the twentieth year. 
The order in which union occurs is exactly the reverse 
of the order in which ossification commences, the 
lower epiphysis being the first to exhibit traces of 
ossification, and the last to unite. 

Division of Fractures. — Of 236 fractures of the 
femur, not including gunshot, which have been re- 
corded by me, 114 belong to the upper third, 86 to 
the middle third, and 36 to the lower third ; or, if Ave 
confine our analysis to the shaft alone, 30 belong to 
the upper third, 80 to the middle, and 36 to the 
lower. 

(I have personally examined many more cases of 
fracture of the femur than are above enumerated, but 
these include all which have been subjected to this 
species of analysis.) 

Dr. Frederick E. Hyde, in his analysis of 322 
cases in Bellevue Hospital, states that 95 occurred 
in the upper third (including fractures of the neck) ; 
169 in the middle third, and 38 in the lower third 
(including the condyles). In the 20 remaining cases the point of frac- 
ture is not stated. 

To give a summary of these valuable tables more in detail, 61 be- 
longed to the neck, of which 14 are stated in the records to be intra- 
capsular, 17 extracapsular, and thirty undetermined. Thirty-four were 
in the upper third of the shaft ; 169 in the middle third, and 31 in the 




Development of femur. 
(From Gray.) 



NECK OF THE FEMUR. 393 

lower ; the exact point of fracture of the shaft being undetermined in 
20; 7 fractures belonged to the condyles. 1 

The femur constitutes, therefore, a striking exception to the rule 
which my observations have established, that in the case of the long- 
bones the lower third is most often the seat of fracture. The shaft of 
the femur is most often broken in the middle third, and generally near 
the upper end of this third : that is to say, above its middle. 

§ 1. Neck of the Femur. 

Eighty-four of the whole number recorded and analyzed by myself 
were fractures of the neck, either intra- or extracapsular. The youngest 
of these patients, excepting one case of supposed epiphyseal separation, 
was twenty-nine years, the oldest eighty-four; forty -five were males 
and thirty-nine females. Nearly all were simple. Forty-two were be- 
lieved to be without the capsule, and thirty were believed to be within; 
the remainder were undetermined. 

We have already given the number of fractures of the neck, both 
intra- and extracapsular, reported in Dr. Hyde's tables. Having refer- 
ence to age, 19 years was the youngest, and 85 the oldest; 20 years 
and under presented two cases; from 20 years to 30. five cases; from 
30 to 40, nine ; from 40 to 50, eight; from 50 to 60, fourteen ; from 60 
to 70, fifteen ; from 70 to 80, seven; from 80 to 90, one. Of the whole 
number, thirty-nine were males, and twenty-two females ; none of the 
fractures were compound ; fourteen are recorded as of the right leg ; 
seventeen of the left ; and thirty are undetermined. Fourteen were 
diagnosticated as intracapsular, and seventeen as extracapsular, thirty 
beins; undetermined. 

Surgeons have differed in their opinions as to the relative frequency 
of fractures of the neck of the femur within or without the capsule. 
This has arisen, no doubt, in part from the difficulty and probable inac- 
curacy of many of the diagnoses. Malgaigne, who has adopted a mode 
of deciding this question which, it must be conceded, is much less liable 
to error than simple clinical observation, namely, an examination of 
cabinet specimens, finds in four large collections sixty-one intracapsular 
fractures, and only forty-two extracapsular. So that, according to his 
observations, they stand in the proportion of about three to two ; the 
intracapsular being the most common. On the contrary, .Nelaton be- 
lieves that extracapsular fractures are much the most common, and 
Bonnet, of Lyons, affirms that they constitute the immense majority. 
Bonnet made four dissections, and in each case he found the fracture 
extracapsular. This testimony, so far as it goes, is positive, but the 
number is not sufficient to establish anything more than a probability in 
favor of the greater frequency of extracapsular fractures. 

Clinical observations are in this case too uncertain to be made avail- 
able in so nice a question. Cabinet specimens may have been collected 
for a special purpose, and this is well known to have been the fact with 

1 Hyde, Analysis of 322 cases of Fracture of the Femur, at Bellevue Hospital, from 
1865 to 1873, inclusive. Medical Record, 1875. 
26 



394 FRACTURES OF THE FEMUR. 

the celebrated Dupuytren collection, the specimens in which constitute 
nearly one-third of the whole number referred to by Malgaigne. I 
allude to the effort which was made while the controversy was pending 
between Dupuytren and Sir Astley Cooper as to the probability of bony 
union in intracapsular fractures, to accumulate cabinet specimens of this 
fracture ; and which effort extended itself, no doubt, both to London and 
Dublin, from which sources alone Malgaigne has gathered the balance of 
his figures. In Dr. Mutter's collection, at Philadelphia, I think there 
are only three examples of intracapsular fracture, to seven extracapsular. 

Dr. Reuben D. Mussey, of Cincinnati, has in his cabinet twelve ex- 
amples of fractures of the neck of the femur without the capsule, and 
only ten within. 

We ought, therefore, to regard the question of relative frequency as 
still undetermined. Nevertheless it is my opinion that the extracapsular 
fracture is very much the most frequent. 

(a) Neck of the Femur within the Capsule. 

Causes. — In no other fractures do the predisposing causes play so im- 
portant a part as in fractures of the neck of the femur, and this whether 
within or without the capsule ; indeed, experience has shown that Avithout 
the concurrence of those pathological changes which usually accompany 
old age, these fractures can scarcely occur. 

Dr. Merkel considers the fragility of the neck, within the capsule, in 
old persons, due to the absorption of that process of the cortical sub- 
stance which arises from about the level of the trochanter minor, and 
ends close under the head of the bone, at the anterior part of the neck ; 
thus occupying the situation where the greatest pressure is made in the 
erect position. This process he calls the " calcar femorale." In newly- 
born children it is absent; it appears when they begin to walk, attains 
its greatest development in middle age, and completely disappears in old 
persons. 1 Dr. Merkel says that no account has hitherto been given of 
this process ; but this statement is scarcely correct, inasmuch as it has 
been both described and represented by various surgical and anatomical 
writers for a long time (see Fig. 126 of this volume). The fact of its 
absorption in advanced life is, however, an original observation. 

Sir Astley Cooper thought that the majority of fractures of the neck 
after the fiftieth year were intracapsular ; but Robert Smith has given 
us the ages of sixty persons having fractures of the neck of the femur, 
and the average age of thirty-two in whom the fractures were within the 
capsule, is sixty-two years, while the average age of twenty-eight in 
whom the fractures were extracapsular, is sixty-eight years. Malgaigne 
has referred to this testimony in proof of the inaccuracy of the opinion 
held by Sir Astley Cooper ; but 1 trust it will not be regarded imperti- 
nent or hypercritical for us to inquire how Mr. Smith became possessed 
of the ages of all these persons from whom these specimens were ob- 
tained ; for more than half of the whole number, that is, just thirty-two, 
have their ages set down in round decimals, such as 50, 60, 70, etc., and 

1 Merkel, Am. Journ. Med. ScL, Jan- 1874. 



NECK, WITHIN THE CAPSULE 



395 



Fig. 123. 



it would be easy to show by the inevitable law of chances, that this could 
not possibly be a true statement. If Mr. Smith does not pretend to 
have given the ages with accuracy, but only to have arrived as near to 
the truth as his sources of information would permit, then I protest that 
these tables do not constitute proper evidence in relation to this point ; 
and until better evidence is furnished I 
shall continue to think, with Sir Astley 
Cooper, that fractures within the capsule 
belong generally to an older class of sub- 
jects than fractures without the capsule. 
This opinion, confirmed by my own ex- 
perience, does not, however, as Mal- 
gaigne seems to think, imply that frac- 
tures within the capsule may not occa- 
sionally occur in persons much younger 
than the average limit, namely, under 
fifty years. 

Dr. Hyde's tables present two cases 
under 50 years, and twelve at or over 



50. Of the two under 50 



years 



of 



years. 



one 



aa'e. 



and the other 89. 




Fracture within the capsule. 



was 48 

Of course the reader will make what 
allowance he shall think proper as to the 
accuracy of these diagnoses, inasmuch as 
such diagnoses are notoriously difficult, 
and often inaccurate. 

It is also believed that intracapsular fractures are more frequent in 
women than in men. In Dr. Hyde's tables there are ten females and 
four males. 

The position of the neck of the femur, and the great thickness of the 
muscular coverings, render its fracture from a direct blow a very rare 
circumstance ; indeed, it can only happen as the result of gunshot acci- 
dents, or other similar penetrating injuries. 

It is broken therefore usually by indirect blows, such as a fall upon 
the bottom of the foot, upon the knee, or upon the trochanter major ; or 
by muscular action alone, as has sometimes happened with very old peo- 
ple, who, in walking across the floor, have tripped upon the carpet, break- 
ing the bone in the effort to sustain themselves. We must not always 
infer, however, because the patient has tripped, that the bone was broken 
by muscular action ; since it is quite as likely that the fall, consequent 
upon the tripping, has occasioned the fracture ; and we ought in such 
cases to make a careful examination of the hip over the trochanter to 
ascertain whether it has been bruised, and to interrogate the patient as 
to the manner of the fall. 

Rodet has attempted to show by a series of experiments made upon 
the dead subject, and by other observations, that the direction in which 
the force had acted will determine the situation and direction of the frac- 
ture. Thus he maintains that when the person has fallen upon the foot 
or knee, the fracture will be intracapsular and oblique ; that if the front 
of the trochanter receives the blow, the fracture will be intracapsular 



396 



FRACTURES OF THE FEMUR. 



Fig. 124. 



also, but transverse ; if the back of the trochanter is struck, the fracture 
will be partly intra- and partly extracapsular ; and if the person falls 
directly upon the side, or receives the blow fairly upon the outer side of 
the trochanter, the fracture will be entirely without the capsule. 1 

Without intending to give my unqualified assent to these propositions 
so ingeniously maintained by Roclet, I am nevertheless prepared to admit 
their general accuracy ; and especially has my experience led me to 
believe that falls upon the feet or knees in most cases produce intracap- 
sular fractures, and that falls upon the outside of the hip, or upon the 
great trochanter, generally produce extracapsular fractures. There are, 
however, frequent exceptions to this latter proposition. Especially have 
I observed that in persons over fifty years of age, or somewhat advanced 
in life, a fall upon the trochanter has caused an intracapsular fracture. 
The following case, verified by an autopsy, is conclusive : — 

A man, 75 years of age, was received at Belle vue March 24, 1875. 
He stated that on the same day he had slipped and fallen upon the side- 
walk, striking with great force upon the trochanter. The house surgeon, 

Dr. E. A. Lewis, examined the limb 
immediately on admission, and diagnos- 
ticated an intracapsular fracture. I saw 
him during the day and confirmed the 
diagnosis. He was feeble, but not suf- 
fering much, apparently, from shock or 
from pain. Food and stimulants were 
administered, but no surgical treatment 
was adopted. On the following morning 
he was found to be sinking, and he died 
before night. No complete autopsy was 
obtained, and the cause of his death is 
undetermined. After death Drs. Dennis 
and Isham repeated the examination, and 
found the evidences of an intracapsular 
fracture very marked, including a slight 
crepitus and rotation of the trochanter 
upon a short axis. The accompanying 
wood-cut, taken from the specimen now 
in the possession of Dr. Dennis, shows that the fracture was close to the 
head, and, of course, entirely intracapsular. It was not impacted, and 
no absorption of the neck had taken place. 

Pathology. — I have already, when speaking of partial fractures, ex- 
pressed my conviction of the possibility of a partial fracture, or a fissure 
of the neck of the femur, and I have referred to the case reported by Dr. 
J. B. S. Jackson, of Boston, as having determined this question beyond 
all possibility of a doubt ; yet its occurrence must be regarded as an 
exceedingly rare, and, we may say, improbable event. 

It is much more common to meet with examples of complete fractures 
of the neck both within and without the capsule, unaccompanied with a 
rupture of either the periosteum or the reflected capsule. Such was the 




Intracapsular fracture, caused by a fall 
upon the trochanter. 



L" Experience, March 14, 1844. 



NECK, WITHIN THE CAPSULE. 



397 



fact in eight cases examined by Colles ; in three of which, however, he 
believed the fracture not to have been complete, but Robert Smith thinks 
they were all of them examples of complete fracture. 1 Stanley has also 
related a case of complete separation of the bone unaccompanied with 
laceration or injury of either the periosteum or capsular ligament. This 
was in the person of a man aged sixty years, who had been knocked 
down in the street. On being admitted into St. Bartholomew's Hos- 
pital, shortly after the injury, he complained of pain in the hip, but there 
was neither shortening nor eversion of the limb, and its several motions 
could be executed with freedom and power. A fracture was not sus- 
pected ; but five weeks after this he died of inflammation of the bowels. 
The dissection showed a fracture extending through the neck, accompa- 
nied with a slight bloody effusion, but no displacement of the fragments 
or laceration of the soft parts. 2 

In other examples the bone is not only broken, but displaced to such 
an extent that the capsule is completely torn in two. 

But in a large majority of cases both the capsule and the periosteum 
are only partially torn asunder. 

The intracapsular fracture is generally somewhat oblique, and its 
direction is usually from above downwards, and from within outwards. 
Sometimes its direction is such as to include a portion of the head ; oc- 
casionally it is quite transverse. In one example of an old fracture I 
have seen the ends dovetailed upon each other, the fracture having a 
double obliquity, and not admitting of displacement. 

There may occur also a species of impaction, the lower portion of the 
neck entering the cancellous structure of the head, while its upper por- 
tion rides upon the articular surface, a cir- 
cumstance which is well illustrated by the 
annexed wood-cut (Fig. 125), copied by 
Mr. Smith from a specimen in the Dupuy- 
tren Museum at Paris ; or the impaction 
may occur without any degree of either up- 
ward or lateral displacement. 

Mr. Liston says : " Even in children sepa- 
ration of the head of the bone may, on good 
grounds, be supposed occasionally to take 
place ;' r3 by which Ave understand him to 
mean that a separation of the epiphysis 
which completes the head of the femur may 
occur. Mr. South relates a case in a boy 
ten years of age, who had fallen out of a 
first-floor window upon his left hip. The 
limb was slightly turned out, but scarcely 

at all shortened. The thigh could be readily moved in any direction 
without much pain, but on bending the limb and rotating it outwards, a 
very distinct dummy sensation was frequently felt, apparently within the 



Fig. 125. 




Impacted fracture within the capsule. 



1 Colles, Dublin Hosp. Rep., vol. ii. p. 339. 

2 Stanley, Med. Chir. Trans., vol. xiii. 

3 Liston, Elements of Surgery, Phila. ed., 1837, p. 480. 



398 FKACTURES OF THE FEMUR. 

joint, as if one articular surface had slipped off another. This was re- 
garded by Mr. South and Mr. Green as an example of epiphyseal sepa- 
ration, and he was placed upon a double-inclined plane, but he felt so 
little inconvenience from it that he several times left his bed and walked 
about. We have no information as to the result or as to the further 
progress of the case. 1 According to Erichsen, M. Stanley reported a 
case in a lad of 18 years. 

A girl, aet. 18, was brought before Dr. Parker, of New York, at his 
surgical clinic, Nov. 1850, who had been injured by a fall upon a curb- 
stone, when eleven years old. The accident was followed by suppuration 
and a fistulous discharge, from which, however, she finally recovered, but 
with the foot everted, and a shortening of one inch and a half. "Flexion 
and rotation of the joint occasioned no inconvenience." Dr. Parker 
thought this circumstance alone sufficient to distinguish it from hip dis- 
ease in which anchylosis is the termination. 2 

At a meeting of the Kappa Lambda Society, held in New York, March 
25, 1840, Dr. Post mentioned a case which he had seen in a girl sixteen 
years old, who, in taking a slight step with a child in her arms, made a 
false movement, and feeling something give way, she was obliged to lean 
against a wall. Dr. Post saw her the next day, when he found the 
affected limb one inch shorter than the opposite one, movable, the toes 
turned outwards, no swelling, some slight pain at the upper part of the 
thigh. The trochanter major moved with the shaft. There was also 
crepitus. From the age of the patient, and the slight amount of violence 
by which the injury was produced, Dr. Post thought a separation of the 
epiphysis of the head had taken place. The extending apparatus was 
applied, but the limb remains from a quarter to half an inch shorter than 
its fellow. 3 

Aug. 14, 1865, Andrew Leroy, jet. 15, in attempting to escape from 
the House of Refuge, fell from the fourth story. On the following morn- 
ing he was admitted into my wards, at Belle vue Hospital. I found his 
right thigh shortened three-quarters of an inch, and slightly abducted ; 
toes everted. Placing him under the influence of chloroform, we detected 
a full crepitus in the vicinity of the joint. It was unlike the crepitus 
of broken bone. With fifteen pounds of extension we were able to over- 
come the shortening entirely, and to put the limb in position. This was 
maintained with Buck's apparatus. At the end of two weeks, however, 
it was ascertained to be shortened half an inch. Four more pounds were 
then added. At the close of my term of service I lost sight of the boy, 
and have not been able therefore to verify my diagnosis ; but I believe 
it to have been a separation of the upper epiphysis. 

Dr. H. Wardner, of Cairo, 111., has reported a case of " intra-capsular 
fracture of the neck of the femur" in a boy fourteen years of age. 4 He 
does not state that he regarded it as epiphyseal, but his remarks lead us 
to suppose that he did. The lad had hurt himself by jumping and alight- 

1 South, note to Chelius's Surgery, vol. i. p. 619. 

2 Parker, Amer. Med. Gazette, vol. i. p. 342, Nov. 30, 1850. 

3 Post, New York Journ. Med., vol. iii. p. 190, July, 1840. 

4 Wardner, a paper read before the Southern Illinois Med. Assoc, at Arena, Illinois, 
June, 1877. 



NECK, WITHIN THE CAPSULE. 399 

ing upon his feet, this being followed by a lameness in the hip-joint and 
some difficulty in walking. Twenty-four days later, on " attempting to 
get out of bed, one foot became entangled in the bedclothing, and this 
led him to exert forcibly the adductor muscles, when he suddenly cried 
out with pain, saying his hip had gone out of place, and he found him- 
self unable to rise." 

Dr. H. S. Smith, of Blandville, and Dr. Swett, being called, thought 
it a dislocation, and under chloroform attempted reduction, but unsuc- 
cessfully. Dr. Smith has since informed me by letter that he did not at 
that time detect crepitus. The day following Dr. Wardner was called, 
and in his report of the case he says the limb was shortened one or tAvo 
inches, and was lying nearly parallel with the other limb, with the toes 
rotated. 

Dr. W. detected a "dull crepitation," and, regarding it as a fracture, 
made extension, and maintained it for several weeks, or until the cure 
was effected, when " the injured limb was of the same length as the sound 
one, and no deformity of any kind was detected." By a letter, how- 
ever, dated Feb. 2, 1875, thirteen months after the accident, from Dr. 
Smith, I am informed that there was then a shortening of one inch, and 

that the published statement of Dr. was derived from the father 

through Dr. Smith, and that he now found it to be incorrect. 

Dr. Smith farther states, " The motions of the hip-joint are limited to 
about one-half the normal extent, the muscles, leg, etc., of that side of the 
pelvis are considerably shrunken, he walks a little lame, and complains 
of weakness of the limb." ... "I think there can be no doubt that 
the neck of the femur was fractured." 

It will be noticed that the first measurement was so indefinite that Dr. 
Wardner could only declare it " one or two inches" shortened; nor am 
I assured by Dr. Smith that the shortening observed by him Avas deter- 
mined by measurement, although I presume it was. 

These six constitute the only examples of this accident which I find 
reported or of which I have any knowledge, and, although there may be 
much reason to suppose that the diagnosis was correct in each instance, 
I cannot regard any one of them as actually proven ; nor can I admit 
the accident as fairly established, or the diagnostic signs as being pro- 
perly made out, until these important points have received the confirma- 
tion of at least one dissection. 

Symptoms. — (We are speaking now only of true fractures, having as 
yet no means of determining the symptoms of epiphyseal separations.) 
Whether the limb will be shortened or not must depend upon whether the 
fragments are impacted, or have become displaced in the direction of the 
axis of the shaft of the femur. It is w T ell established that in this fracture 
the broken ends frequently remain in contact for several hours or days, 
or until the gradual contraction of the muscles or the weight of the body 
upon the limb occasions a separation, and that consequently there is often 
at first no appreciable or actual shortening of the limb. To determine, 
however, its existence, it is not sufficient to lay the patient upon his back, 
and place the limbs beside each other ; we ought also to measure care- 
fully with a tape-line from the pelvis to the leg or foot, and from various 
other points, until Ave have placed this question beyond a doubt. 



400 FRACTURES OF THE FEMUR. 

If shortening occurs, it may vary from one-quarter of an inch to two 
inches, or even more ; but this extreme shortening is not reached usually, 
except after the lapse of several weeks or months, when the ligaments 
have gradually given way under the weight of the body in walking, or 
not until the neck has undergone a partial or almost complete absorption. 

Sir Astley Cooper has stated that a shortening to this degree may 
occur at once ; but Boyer, Earle, and others doubt the accuracy of this 
opinion, and Robert Smith declares that he does not think the capsule 
would admit of such an amount of immediate displacement, unless it 
were extensively torn, an occurrence which he thinks very rare indeed. 

With this qualification, the opinion of Mr. Smith does no't differ from 
that entertained by Sir Astley, who only admits its possibility as a rare 
event ; in a large majority of cases the shortening does not at first ex- 
ceed one inch. Of the methods of measurement I shall speak hereafter. 

Crepitus, unlike shortening, is generally absent when the displace- 
ment of the fragments is complete ; but under no circumstances is it 
easily developed. When the fragments remain in apposition, and the 
femur is rotated for the purpose of moving the broken surfaces upon 
each other, the small acetabular fragment, resting in a smooth cup-like 
socket, and holding upon the opposite fragment by denticulations or by 
the untorn periosteum, or capsule, glides about in obedience to the motions 
of this latter, and no crepitus can be produced. Nor is the difficulty 
rendered less by pressing firmly upon the trochanter, as some surgeons 
have recommended, since, while this pressure tends, no doubt, to fasten 
the upper fragment in the acetabulum, it tends much more to fasten the 
broken ends together, and thus defeats the purpose in view. When, on 
the other hand, the fragments have become completely separated, it is 
almost impossible to bring them again into contact. The limb may, per- 
haps, be easily brought down to the same length with the other, but it 
must by no means be inferred that, constantly, the broken ends are in 
apposition. It is almost certain, indeed, that in its progress downwards 
the trochanteric fragment has caught upon the acetabular fragment, and 
pushed its floating and broken extremity downwards before it. Under 
these circumstances, the discovery of a crepitus must be accidental, and 
is scarcely to be looked for. Sometimes, however, we may recognize a 
sound not unlike crepitus, but less harsh, produced by the friction of the 
trochanteric fragment against the rim of the acetabulum or dorsum of 
the ilium. 

One thing we ought never to forget, namely, that by extraordinary 
efforts to obtain a crepitus w y e may lacerate the capsule or produce a dis- 
placement of the fragments which we never can remedy, and which, 
without such unwarrantable manipulation, might never have occurred. 

Eversion of the foot is almost uniformly present in some degree, tak- 
ing place immediately or more gradually, in proportion as the fragments 
become displaced, and the external rotators contract. The opposite con- 
dition, or an inversion of the foot, is occasionally present, and sometimes 
also the foot is neither turned in nor out, but the toes point directly for- 
wards. In sixty cases of fracture of the neck seen by Cloquet the foot 
was never turned in, and Boyer never met with such an example in all 
of his immense experience; but Langstaff, Guthrie, Stanley, and Cruveil- 



NECK, WITHIN THE CAPSULE. 401 

hier have each seen one example, and Robert Smith has seen two. 1 I 
have myself seen one. 

The explanation of the fact that the foot is usually everted is not diffi- 
cult. In the case of an intracapsular fracture it is probably due, first, 
to the relative friability of the laminated or cortical structure on the 
posterior aspect of the neck, in consequence of which this portion gives 
way more readily than the cortical structure on the anterior aspect ; 
second, to. the natural form and position of the foot and leg, which in- 
cline them to fall outwards by their own weight ; and third, to the power- 
ful action of the external rotators, which are so feebly antagonized upon 
the opposite side. 

In the case of an extracapsular impacted fracture, in addition to the 
second and third causes assigned as influencing the position of the limb 
in intracapsular fractures, there are other special causes. The cortical 
lamina on the posterior aspect of the neck, everywhere more frail than 
upon the anterior aspect, becomes greatly weakened as it approaches the 
trochanter by dividing itself into two laminae, one of which penetrates 
toward the centre of the bone, and the other, the thinnest of the two, 
being scarcely thicker than a sheet of paper, forming the wall of the 
bone as it becomes continuous with the trochanter. This delicate papery 
wall easily gives way under the application of force, while the anterior 
wall yields only partially, constituting thus a sort of hinge upon which 
the rotation of the thigh is performed. It is probable, also, as suggested 
by M. Robert, that the angle at which the external surface of the tro- 
chanter unites with the neck increases the tendency to fracture and im- 
paction posteriorly. 

An explanation of the fact already stated, that in rare and excep- 
tional cases the limb is inverted or the toes are permitted to point directly 
forwards, has been thought to be more difficult. Dr. Bigelow has had 
an opportunity of examining a specimen taken from an old woman in the 
dissecting-room, and he concludes that the inversion was due to the ex- 
tent of the comminution, which had separated the Avails of the shaft so 
as to receive in the interval the whole neck, instead of the posterior wall 
only, as commonly occurs. Dr. Robert Smith, of Dublin, cites a similar 
case verified by the autopsy; and Dr. Bigelow remarks that the speci- 
men numbered 248, in the Mutter museum, at Philadelphia, presents the 
same kind of impaction without either inversion or e version. 

Fracture of the neck of the femur within the capsule is not usually 
attended with much pain when the patient is at rest, but any attempt to 
move the limb produces intense suffering, and especially when an attempt 
is made to rotate the limb inwards, or to carry it upwards and inwards. 

Occasionally, also, during the first few days or hours after the frac- 
ture, a spasmodic action of the muscles compels the patient to cry out 
from the severity of the pain which it produces. At first the sufferer 
is unable to indicate clearly the seat of this pain, or, perhaps, it is dif- 
fused and uncertain in its position ; but after a time he is able to refer 
it chiefly to the region of the groin, opposite the neck of the bone, or 
to near the point of attachment of the psoas magnus and iliacus internus. 

1 Robert Smith, op. cit., p. 25. A. Cooper by B. Cooper, op. cit., p. 151, note. 



402 



FRACTURES OF THE FEMUR. 



There is also usually in this region a great degree of tenderness and an 
unusual fulness. 

If now the limb be seized, and extension gradually but firmly applied, 
it will be soon made of the same length with the opposite thigh ; but, the 
moment the extension is discontinued, the shortening and eversion will 
recur, accompanied with pain, and perhaps crepitus. 



Fig. 126. 



Fig. 127. 





Horizontal section of neck of femur. 
(From Bigelow.) 



Extracapsular fracture, with inversion. 
(From Bigelow.) 



The trochanter major is less prominent than upon the opposite side, 
and if eversion of the limb exists, the trochanter may be felt indistinctly 
upwards and backwards from its usual position. The patient having 
been placed under the influence of an anaesthetic, we may prosecute the 
investigation still farther, and by rotating the limb inwards and outwards 
as far as it will admit, we shall notice that the trochanter describes the 
arc of a smaller circle than in the opposite limb, or that the length of 
its radius has been shortened. It ought to be said at once, however, 
that this amount of manipulation is often injurious, and seldom proper. 

The patient is generally unable to move his limb, or to bear the least 
weight upon it ; but many examples are on record of persons who 
walked some distance after the fracture had taken place, the capsule, 



NECK, WITHIN THE CAPSULE. 403 

and perhaps also the periosteum, not being torn, and consequently the 
fragments not being displaced ; or, possibly, it was at first an impacted 
fracture. 

On the 6th of May, 18T5, Mrs. R., of Brooklyn, was ascending a 
flight of steps when her limb suddenly gave way under her, in conse- 
quence of an intracapsular fracture. Mrs. R. was 78 years of age, large, 
and rather fat. For several years she had suffered from rheumatism of 
the right leg, which compelled her, in walking, to bear her weight chiefly 
on the left, and it was this limb which gave way. She was assisted to 
her feet, and with the aid of her daughter ascended another flight of 
steps, bearing some weight on the broken leg. On the following day 
she got out of bed alone, and unaided, walked a few steps moving her 
limb very carefully. On the same day I saw her and found her in bed, 
the limb shortened half an inch and slightly everted. The head of the 
femur moved with the trochanter and without causing crepitus or pain. 
There was very little tenderness about the hip or groin ; no swelling, 
and only a heavy, dull aching pain in the limb. The age, the manner 
of the accident, and the shortening of the limb were the only signs of 
fracture, but these were sufficient. 

Finally, after having examined the patient as well as we are able to 
do, in the recumbent posture, if any doubt remains, and it is found prac- 
ticable for the patient to be elevated upon his sound foot, this should be 
done. The broken limb can now be examined thoroughly on all sides, 
and a more accurate opinion formed of the amount of shortening and 
eversion. It will be especially noticed that if the weight of the body is 
allowed to rest upon the limb, in most cases it produces insupportable 
pain. 

M. Maisonneuve has lately suggested and practised the following 
method of diagnosis in certain doubtful cases. Lay the patient flat on 
his belly, and then bring the suspected thigh into extreme extension 
backwards. If it is not broken, the neck will strike against the pos- 
terior lip of the acetabulum and the progress of the thigh in this direc- 
tion will be arrested. If it is broken, it can be carried backwards much 
farther. 1 Of this method as a means of diagnosis, it seems proper to 
say that, if the fragments have slid past each other and the limb is short- 
ened, it is unnecessary ; and if they are still in apposition, it will be 
pretty certain to cause displacement, and thus do irreparable mischief. 

JP 'ro gnosis. —The question of bony union after a complete fracture of 
the neck of the femur within the capsule has occupied the attention of 
the ablest surgeons and pathologists for a long period ; and while great 
differences of opinion have been expressed as to the probability of the 
occurrence, and as to the value of the testimony on the one side or the 
other, very few have ventured to deny its possibility. 

Among these latter are found, however, the distinguished names of 
Cruveilhier, Colles, Lonsdale, and Bransby Cooper. It has been re- 
peatedly affirmed, also, that Sir Astley Cooper taught the same doctrine, 

1 Maisonneuve, Traite du Diagnos. Malad. Cliir., par Em. Foucher, tom. i. prem. 
part. p. 287. 



404 FRACTURES OF. THE FEMUR. 

but with how much show of reason, the following paragraphs from his 
own pen will determine : — 

" In the examinations which I have made of transverse fractures of the 
cervix femoris, entirely within the capsular ligament, I have only met 
with one in which a bony union had taken place, or which did not admit 
of a motion of one bone upon the other. To deny the possibility of this 
union, and to maintain that no exception to the general rule can take 
place, would be presumptuous, especially when we consider the varieties 
of direction in which a fracture may occur, and the degree of violence 
by which it may have been produced. For example, when the fracture 
is through the head of the bone, with no separation of the fractured 
ends ; when the bone is broken without its periosteum being torn ; or, 
when it is' broken obliquely, partly within and partly externally to the 
capsular ligament, I believe that bony union may take place, although 
at the same time I am of opinion that such a favorable combination of 
circumstances is of very rare occurrence. Much trouble has been taken 
to impress the minds of the public with the false idea that I have denied 
the possibility of union of fracture of the neck of the thigh-bone, and 
therefore I beg at once to be understood to contend for the principle 
only, that I believe the reason that fractures of the neck of the thigh- 
bone do not unite, is that the ligamentous sheath and periosteum of the 
neck of the bone are torn through, that the bones are consequently drawn 
asunder by the muscles, and that there is a want of nourishment of the 
head of the bone ; but I can*readily believe, if a fracture should happen 
without the reflected ligament being torn, that as the nutrition would 
continue, the bone might unite ; but the character of the accident would 
differ ; the nature of the injury could scarcely be discerned, and the pa- 
tient's bones would unite with little attention on the part of the surgeon. 

" In proof of the correctness of my opinion, I enumerated in the early 
editions of this work, forty -three specimens of this fracture, in different 
collections in London, which had not united by bone. At the present 
clay these might be multiplied, were it necessary. 

" Such has been the accumulated evidence of the want of power of the 
neck of the femur to unite by bone, in my practice of forty years, during 
which period I have seen but two or three cases which militate against 
this opinion, for many of the preparations which have been brought for 
my inspection as specimens of united fractures of this part have proved 
to be nothing more than the result of the changes concomitant with old 
age ; and in many of them the two thigh-bones of the same subject had 
undergone the same alteration in texture and in form." 1 

The following passages from a communication made by Sir Astley to 
the London Medical Gazette, for the 25th of April, 1834, are equally 
pertinent: — 

" I find in a report of the Baron Dupuytren's lecture that he attrib- 
utes to me the opinion that fractures of the neck of the thigh-bone, within 
the capsular ligament, not only ' never unite, but that it is impossible 
that they should unite by bone.' 

1 Sir Astley Cooper on Dislocations and Fractures of the Joints, edited by Bransby 
Cooper, Amer. ed., p. 156. 



N.ECK, WITHIN THE CAPSULE. 405 

" It is quite true that, as a general principle, I believe that those frac- 
tures unite by ligament, and not by bone, as do those of the patella and 
olecranon. But I deny that I have ever stated the impossibility of their 
ossific union ; on the contrary, I have given the reason why they may 
occasionally unite by bone. 

" The following are my words : ' To deny the possibility of their union, 
and to maintain that no exception to this general rule may take place, 
would be presumptuous,'" etc. etc. 

In conclusion, Sir Astley remarks : "I should not have given you 
this trouble, nor should I have taken it myself, but for the respect I 
bear my friend, the Baron Dupuytren ; for although I have already sub- 
mitted myself to be misrepresented by many individuals, yet I should be 
sorry to be misunderstood by so excellent a surgeon and so valuable a 
friend as Le Baron Dupuytren." 1 

Sir Astley, then, so far from denying, frankly admitted the possibility 
of bony union when the neck was broken within the capsule, and ex- 
plained the circumstances under which he believed it might occur. The 
true point in dispute was, whether certain cabinet specimens were actually 
examples of complete fractures, wholly within the capsule, united by 
bone. Some of them Sir Astley thought were only examples of chronic 
rheumatic arthritis, or of interstitial and progressive absorption. Some 
were partial rather than complete fractures ; others were partly within 
and partly without the capsule ; and for this he was accused of wilful 
blindness or stupidity, chiefly by those who" themselves being owners of 
these rare pathological treasures, might possibly have felt somewdiat 
annoyed at seeing their value thus depreciated, and who, no doubt, would 
be quite as apt to fall into blindness and partisanship as Sir Astley him- 
self. The truth is, however, that although the claim has been set up and 
stoutly maintained for more than thirty cabinet specimens, in one part of 
the world or another, a majority of these, including several whose claims 
were urged upon Sir Astley, have been at length declared by all parties 
unsatisfactory, or absolutely fictitious, and only a fraction of the whole 
number continue to be mentioned by any surgical writer as probable 
examples. 2 

1 See also Sir Astley's letter to Prof. Cox, written in 1835, and jniblished in the 
Prov. Med. and Surg. Journ. for July 12, 1848, New York Journ. Med. for Sept. 1848, 
and appendix to Cooper on Dis. and Frac, Amer. ed., 1851, p. 482. 

2 The following European surgeons have claimed to have in their possession, each, 
one example : Langstaff (Med.-Chir. Trans., vol. xiii. 1827) ; Brulatour (Ibid., vol. 
xiii. 1827) ; Stanley (Ibid., xviii.) ; Swan (Swan on Diseases of Nerves, p. 304) ; 
Adams (Todd's Cyclop., p. 813); Jones (Med.-Chir. Trans., vol. xxiv.) ; Chorley 
(Amesbury on Frac, p. 125) ; Field (Ibid., p. 128) ; Soemmering (Chelius's Surgery 
by South, vol. i. p. 621) ; South (Ibid., p. 621). South also mentions another exam- 
ple as being in the museum of St. Bartholomew's Hospital. This is probably Jones's 
case, which Robert Smith says is preserved in this museum, and which has already 
been enumerated. Bryant (Memphis Med. Rec, vol. vi. p. 108, from British Med. 
Journ., March 14) ; Fawcington (Amer. Journ. Med. Sci., vol. xv. p. 534, from Lon- 
don Med. Gaz., Aug. 16, 1834) ; Harris (Ibid., vol. xviii. p. 246, from Dublin Journ., 
Sept. 1835). Robert Hamilton says that Prof. Tilanus showed him three specimens 
in the museum of the Hospital of St. Peter, at Amsterdam (Ibid., vol. xxxi. 470, from 
Loud. Med. Graz., Jan. 6, 1843). Malgaigne says there are three specimens in the 
Dupuytren museum which have been described with the same interpretation. The 
whole number claimed by transatlantic surgeons is therefere nineteen. 



408 FRACTURES OF THE FEMUR. 

Robert Smith reduces the number to seven, but Malgaigne recognizes 
only three, namely: Swan's case, admitted by Sir Astley himself; 
Stanley's case, and one specimen in the Dupuytren museum. In neither 
of these cases, he affirms, has the neck lost anything of its form or 
length by absorption, from which we are to infer that he would reject 
as doubtful all such specimens as had undergone these pathological 
changes. 

Indeed, I think, we are not left in doubt as to Malgaigne' s opinion 
upon this point. Six of the nineteen cases which I have enumerated 
are declared by him to resemble much more rachitic alterations of the 
neck than true fractures ; and yet Robert Smith admits three of the six 
as well-established examples ; but as to the precise grounds upon which 
he rejects these cases, he shall speak for himself: " And it is sufficient 
that we consider the beautiful drawings designed by Sir Astley Cooper, 
to illustrate certain varieties of the alterations, to place us on our guard 
against every pretended consolidation which presents itself, accompanied 
with a shortening and deformity of the head and neck. When fractures 
unite by bone, they do not suffer such enormous losses of substance 
which it would become necessary to admit for the neck of the femur." 1 

A reference to Stanley's case, as reported by Robert Smith, will 
show that, contrary to Malgaigne' s statement, this was also shortened 
and deformed, and that, consequently, according to his own rules of 
exclusion, it also must be rejected ; after which only two remain, 
namely, Swan's case, admitted by Sir Astley himself, and No. 188 of 
the Dupuytren museum. 

I should do injustice to my own convictions, moreover, were I not to 
refer my readers to the very judicious criticism upon Mr, Swan's case 
made by Dr. Johnson, and published in the New York Journal of 
Medicine, vol. ii. 3d series, p. 295. 

Since writing the above, my friend Dr. Yoss, of this city, has placed 
in my hands an elaborate paper on this subject, from the pen of Dr. 
Edward Zeiss, of Dresden, and which has been translated by Dr. R. 
Newman, Prosector to Chair of Surgery, Long Island College Hospital. 
Dr. Zeiss, after rejecting all other European specimens, claims that bony 
union has occurred within the capsule in a specimen now in his posses- 
sion, and also in a specimen which may be found in the pathological 
cabinet of the Medico- chirurgical Academy of Dresden. 2 I regret that I 
am not able to publish these cases at length, as well, also, as the able 
review of their claims sent to me by Dr. Newman, in which Dr. New- 
man clearly shows that Dr. Zeiss has completely failed to establish the 
correctness of his opinions. There is no conclusive evidence that the 
bones were ever broken, nor, if they were broken, that the fractures 
were entirely within the capsule. 

On this side of the Atlantic, the number of specimens for which the 
honor is claimed is nearly equal to the original number in Europe ; but 
they have not yet, all of them, been subjected to the same sifting pro- 

1 Malgaigne, Traite des Fractures et des Luxations, torn. i. p. 678. 

2 Description of two specimens of intracapsular fractures of the neck of the femur, 
and union by callus, by Dr. Edward Zeiss, Dresden, 1864. 



NECK, WITHIN THE CAPSULE. 407 

cess as their foreign congeners ; and it remains to be seen how many of 
them will come successfully out of a similar fifty years' contest. 

Three of the specimens belonged to Reuben D. Mussey, late Pro- 
fessor of Surgery in the Miami Medical College, at Cincinnati, Ohio. 
He has himself furnished a complete history and description of the 
specimens, accompanied with drawings. 1 One may be found in the Wis- 
tar and Horner Museum at Philadelphia ; 2 one belongs to Willard Parker 
of this city ; 3 two to the Albany College Museum ; 4 two to the Harvard 
Medical College, Boston ; 5 one to the Mutter collection (Specimen B, 
71) ; one to Dr. Pope, of St. Louis. Dr. Sands, of this city, has lately 
presented a supposed example to the New York Pathological Society. 6 
Dr. Adler has presented one to the College of Physicians of Philadel- 
phia. 7 

I will add that Dr. Packard, of Philadelphia, has published an excel- 
lent critical notice of most or all of the published cases, and suggests 
that they all admit of the following explanation : The fractures were 
actually extracapsular ; but, after union took place, that portion of the 
neck attached to the head underwent absorption, until the head was 
brought into contact with the trochanters. 8 

In the former editions of this book I have examined the claims of 
several of these specimens very much at length ; but as new specimens 
are every now and then being presented to our notice, for each of which 
special claims are set up, and inasmuch as no practical results are likely 
to follow upon a further discussion of this point, or upon its definite 
decision, I have concluded to refer those of my readers who feel a par- 
ticular interest in the matter to either one of my earlier editions (first 
four), and to the various monographs to which I have furnished 
references. 

I have also in my own cabinet a femur of no inconsiderable preten- 
sions, belonging clearly to that class of specimens recognized by Robert 
Smith. Its neck is greatly shortened, and this surgeon would regard it, 
I think, as an impacted intracapsular fracture, but its claim would be 
promptly denied by Malgaigne, on account of the absorption and dis- 
tortion of its neck. Its history is as follows : — 

About the year 1833, Mrs. Wakelee, of Clarence, Erie County, New 
York, set. 68, who was then very low with tubercular consumption, 
and so ill as to be scarcely able to walk across the floor, tripped upon 
the carpet and fell, striking upon her left side. She was unable to rise, 
but was laid upon a bed by her son, Dr. Wakelee, a very intelligent 
physician, residing in the same house, who did not suspect a fracture. 
Dr. Bissel saw her on the following day, and, on rotating the limb out- 
wards, he says that he discovered a crepitus. His examination was 
greatly facilitated by her extreme emaciation. 

1 Amer. Journ. Med. Sci., April, 1857. 

2 H. H. Smith's Surgery, p. 399. 

3 Johnson's paper on Intracapsular Fractures, op. cit. 

4 Trans. New York State Med. Soc, 1858. 

5 Bigelow on Dislocation, etc., of Hip, 1869, p. 125. 

6 New York Med. Rec, June 1, 1869. 

7 Am. Journ. Med. Sci., April, 1870. 

8 Am. Journ. Med. Sci., Oct. 1867. 



408 



FRACTURES OF THE FEMUR. 



128. 




Mrs. W. was placed upon a double inclined plane, with apparatus for 
extension, etc., and left in charge of Dr. Wakelee. On the fifth day 

the splint was removed, and from this time 
no dressings of any kind were applied. The 
reason for this change of treatment was, 
that she was likely to live but a few days, 
in consequence of the state of her lungs, 
and that such confinement would only hasten 
her death. Contrary, however, to all ex- 
pectations, she gradually convalesced, so 
that after two or three years she could 
walk on crutches, her toes turning out and 
her limb becoming somewhat shortened. 
Four years after the accident she died, and 
Dr. Bissel obtained from Dr. Wakelee the 
specimen, of which the accompanying draw- 
ing is a faithful delineation. 

Dr. George K. Smith, of the Long 
Island College Hospital, has made a most 
valuable contribution to our knowledge of 
the anatomy and pathology of the hip-joint, 
which will explain in a great measure the 
discrepancies of opinion which at present 
exist among surgeons as to the character 
of certain specimens, and may hereafter 
enable us to decide with more accuracy, and may lead to a better agree- 
ment of opinion. 

His observations prove that anatomists have not hitherto correctly 
described the attachment of the capsule ; that the capsule is seldom, if 
ever, attached at the same point in different persons, while it is as uni- 
formly found attached at the same point in the opposite femurs of the 
same person. In order, therefore, to determine whether the line of 
fracture in any given specimen was without or within the capsule, we 
must always compare the fractured bone with its congener, and not with 
the femur of another person. 

He has further shown that after a fracture, and the consequent ab- 
sorption of the neck, the normal position of the capsule is almost con- 
stantly changed ; so that its present attachment does not declare what 
were the points of its attachment before the fracture occurred ; and 
finally, that the absorption proceeds unequally and irregularly, yet with 
great rapidity, in the two fragments ; and as the bony union, if it ever 
takes place, probably occurs subsequent to the arrest of the absorption, 
the line of union cannot in itself alone determine whether the fracture 
was near the head or near the trochanters. 1 

It seems to me probable that under certain favorable circumstances 
this union will occur ; these favorable circumstances have relation to 
several conditions, such as age, health, degree of separation of the frag. 



Vertical section of Mrs. Wakelee' 
femur, acetabulum, and capsule. 



1 George K. Smith, Insertion of the capsular ligament of the hip-joint, and its rela- 
tion to intracapsular fracture. Medical and Surgical Reporter, Philadelphia, 1862. 



NECK, WITHIN THE CAPSULE. 



409 



Fig. 129. 



ments, laceration of the periosteum and capsule, treatment, etc. Robert 
Smith thinks it is not likely to occur unless the fragments are impacted ; 
but Sir Astley Cooper, as we have already seen, admitted its possibility 
whenever the reflected capsule and the periosteum were not torn, and at 
the sane time the fragments were not displaced. If to these conditions 
we were to add moderate but not extreme age, with good health, we can 
see no sufficient reason why, un- 
der judicious treatment, bony union 
might not occasionally be expect- 
ed. But such a combination of 
circumstances is probably exceed- 
ingly rare ; and, what is more 
unfortunate, if they exist, the frac- 
ture is not likely to be recog- 
nized, and the surgeon will fail to 
avail himself of those advantageous 
coincidences which might, if un- 
derstood and properly treated, 
secure a bony union. Dupuytren 
says, when the fragments are not 
displaced " its existence may be 
suspected, but cannot be positively 
asserted." There will not be 
wanting, however, examples in 
which surgeons will believe or 
affirm that they have recognized 
the fracture and wrought the cure. 
I have heard of many such in- 
stances, and Mr. Smith has re- 
ferred to one, which is quite per- 
tinent, as having been reported 
in the Gazette des Hopitaux. A woman, set. 64, was treated for an 
intracapsular fracture of the neck of the femur at one of the hospitals in 
Paris, and "at the end of four weeks she was discharged perfectly cured, 
and without shortening." We fully partake of Mr. Smith's surprise at 
the impudence of this claim, yet we do not see in it much greater im- 
probability than in Mr. Swan's case, received by both Mr. Smith and 
Sir Astley himself, where the neck was found almost wholly united by 
bone in five weeks, although the woman was 80 years old, and actually 
dying while the process was going on ! Says Dupuytren, " I would lay 
it down as a general principle that all fractures of the neck of a cylin- 
drical bone should be kept at rest twice as long as ordinary fractures of 
the same bone ; and even after that period I have seen displacement take 
place. The term may, therefore, be lengthened to a hundred days, or 
even longer in aged and feeble persons, whose powers of reparation are 
much deteriorated." 

It is not the purpose of the writer to describe particularly all of the 

accidents or pathological conditions with which these fractures may be 

confounded. It is sufficient to allude to them, and leave to others the 

labor of a complete historical record ; but I am tempted to devote a 

27 




Impacted fracture within the capsule. 
Bigelow.) 



(From 



410 



FRACTURES OF THE FEMUR. 



Fig. 130. 



paragraph to what has been variously termed " morbus coxae senilis" 
(Robert Smith) ; " chronic rheumatic arthritis" (Adams) ; " interstitial 
absorption of the neck of the thigh-bone" (B. Bell) ; " rheumatic gout" 
(Fuller) ; and by others " interstitial and progressive absorption ;" but 
the exact nature and cause of which morbid changes are not yet fully 
understood. Mr. Colles does not think this partakes of the nature of 
rheumatism. I have myself a specimen of what has been more generally 
called chronic rheumatic arthritis, occurring in the knee-joint, accompa- 
nied with a flattening and eburnation of the articular surfaces, and Gul- 
liver has shown that similar changes of form in the neck of the bone 
may occur in tolerably young persons. 

I suspect also that it will be found to occur under a greater variety of 
circumstances, and to present a greater variety of forms than have yet 

been described ; and we shall perhaps 
find a partial explanation of this diversity 
and frequency in one single circumstance, 
namely, the peculiar anatomical structure 
of the neck. The neck of the femur 
stands nearly at a right angle with the 
shaft, or at an angle so great as that the 
weight of the body, even in health, has 
the effect to gradually depress the head 
below the top of the trochanter major, 
and to diminish its length. This is seen 
constantly in the striking change of form 
which occurs between childhood and old 
age. Now, if from any cause whatever, 
such as a blow upon the trochanter or 
upon the foot, the neck or head is made 
to suffer ; and inflammation, or perhaps 
only a slight degree of increased action 
in the absorbents, ensues, resulting in an 
equally slight softening of the bony tissue, 
these pathological circumstances may end, sooner or later, in a striking 
change of form in the neck or head. But it is not necessary to suppose 
an external injury to explain the occurrence of this inflammation, and 
consequent softening of the bone ; a scrofulous, or rickety, or tubercu- 
lous constitution may occasion it, and we see no reason why these condi- 
tions are not as likely to lead to a change of form here as in the bones 
of the leg or of the spine. A change of form in the head may be the 
result of an ulceration of the cartilage ; and a change of form in the 
neck, of ulceration of the neck. Among other causes, also, u chronic 
rheumatic arthritis" may operate in a large proportion of those examples 
which belong to advanced life. One case, reported by Gulliver^ would 
seem to show that a deformity may occur here as a result of disease, 
and independently of pressure, 1 yet it is plain, from the direction which 
the deviation of the head and neck usually takes, that pressure performs 
an important part in the causation. 




Section of a sound adult femur. 



1 Gulliver, Loud. Med.-Chir. Rev., vol. xxxix. p. 544. 



NECK, WITHIN THE CAPSULE 



411 



From these various causes, operating in these diverse ways, we shall 
have the different deformities enumerated and described by surgical 
writers. The head flattened, irregularly spread out, depressed and 
polished ; the neck shortened and irregularly thickened and expanded ; 
the trochanter major rotated outwards and drawn upwards ; sinuous 
chasms traversing the neck, produced by ulceration ; and finally, short- 
ening of the neck, by a true interstitial absorption, and with little or no 
increase in its breadth, the trochanter major also being rotated outwards. 



Fig. 131. 




Chronic rheumatic arthritis. (Miller.) 

It would be strange, moreover, if the interior of these bones did not 
present some changes in structure, such as have been frequently ob- 
served, namely, an irregular expansion or condensation of the cellular 
tissue, and which latter might easily be supposed, by one who was inat- 
tentive to all of these circumstances, to indicate the line of an imaginary 
fracture. 

The following example will illustrate the incipient stage of one class 
of these cases, namely, that in which the neck is not only shortened, but 
its surface is irregularly seamed, as if it had been broken and imperfectly 
united. 

William Clarkson, set. 43, was admitted into the Toronto Hospital, 
C.W., May 5, 1858, with tubercular consumption, of which he died on 
the 25th of the same month. 

He had been under the care of Dr. Scott, and it having been noticed 
that he complained of his right hip at the time of admission, an autopsy 
was made on the 25th, at which I was, through the courtesy of the house 
surgeon, permitted to be present. 

We examined both hip-joints, and found the neck of the right femur 
shortened, especially in its posterior aspect. At the junction of the 
head with the neck, posteriorly, and extending about half-way around, 



412 FRACTURES OF THE FEMUR. 

the bone was carious, and so far absorbed as to leave a sulcus of a line 
or two in depth, and of about the same width. Adjacent to this, also, 
the bone was quite soft, yielding under the slightest pressure of the 
knife. There was no other appearance of disease. The opposite femur 
was sound. 

The hospital record furnished the following account of his case, so far 
as the injury to his hip was concerned : — 

About nine months before admission, then laboring under the malady 
of which he finally died, he received a blow upon his right trochanter, 
ever since which he had been lame, and suffered pain in the region of 
the hip-joint. The pain was felt especially in the groin, when the tro- 
chanter was pressed upon, or when the sole of his foot was percussed. 
The thigh was slightly flexed ; the toes a little everted ; and he walked 
with some halt. 

The case of the soldier, Fox, reported by Gulliver, and who died of 
tuberculosis, presents a case also exactly in point, but illustrating a 
later stage, or the completion of the same process. 

Of the precise nature of the changes in the two following examples 
I cannot be certain, since they have not been determined by dissection. 
They will serve, however, to illustrate the usual history and progress of 
a considerable number of cases. They certainly were not examples of 
fracture. 

Ephraim Brown, when twelve years old, fell from a tree and struck 
upon his right foot. Dr. Silas Holmes, of Stonington, Ct., was called. 
Of the particular symptoms at this time, I have only learned that the 
leg was not shortened. The doctor laid a plaster upon his hip, and left 
him without any further treatment. In three days he was able to walk 
on crutches ; in three weeks he walked without crutches, and in four 
months was at work as usual. There was at this time no shortening or 
deformity of any kind. 

Mr. Brown subsequently enlisted as a soldier in the war of the 
American Revolution, and experienced no difficulty in his hip, until 
after a severe illness which followed upon an unusual exposure, when 
he was about thirty-five years old. At this period the leg began to 
shorten, but the shortening was unaccompanied with pain or soreness. 

He consulted me, July 17, 1845, at which time he was eighty -three 
years old, and a remarkably strong and healthy-looking man. The 
shortening, which had ceased to progress some years before, amounted 
at this time to two and a half inches. 

An officer in the United States army addressed to me the following 
letter, dated November 13, 1849 : — 

" My mother-in-law, Mrs. S., of D., some three years since fell down 
a flight of stairs, striking on her side upon a stone, injuring the hip- 
joint severely ; but, upon examination, her physician declared that 
there was neither a fracture nor a dislocation, and said that she would 
gradually recover. Something like one year since the injured limb 
commenced shortening, so that she can now barely touch her toe to 
the floor as she walks. She can bear but little weight upon it, and is 
compelled to use a crutch or a cane constantly. So much time has now 



NECK, WITHIN THE CAPSULE. 413 

elapsed, and the limb is so little better, and constantly becoming shorter, 
I have proposed to ask your opinion," etc. 

I need scarcely say that I had no hesitation in pronouncing this a 
case of chronic inflammation of the bone, accompanied with softening 
and gradual change of form, either of the neck or head, or of both. 

It is proper that I should state briefly, before I leave this subject, 
what constitute the chief difficulties in the way of union by bone within 
the capsule. 

The persons to whom the accident occurs are generally advanced in 
life, and consequently the process of repair is feeble and slow. 

The head of the bone receives its supply of blood chiefly through the 
neck and reflected capsule, and, when both are severed, the small amount 
furnished by the round ligament is found to be insufficient. 

When the fragments are once displaced, it is difficult, as I have already 
explained, if not impossible, to replace them. 

The direction of the fracture is generally such, that the ends of the 
fragments do not properly support and sustain each other when they are 
in apposition. 

The fracture is at a point where the most powerful muscles in the body, 
acting with great advantage, tend to displace the broken ends. 

Aged persons, w T ho are chiefly the subjects of this accident, do not 
bear well the necessary confinement, and especially as the union requires 
generally a longer time than the union of any other fracture ; so that a 
persistence in the attempt to confine the patient the requisite time often 
causes death. 

In all cases in which any degree of displacement exists, except it be in 
the direction of impaction, the ends of the broken fragments are con- 
stantly bathed with the synovial fluid, which must be increased by the 
inflammation resulting from the fracture. Consequently, whatever repa- 
rative bony material is furnished by the broken surfaces must be lost, 
rendering bony union, or even fibrous union from this source impossible. 

Lastly, there is never found in these intracapsular fractures anything 
like provisional callus ; and whatever useful purpose it may serve in other 
fractures, it certainly renders no aid here. 

It remains only to consider what is the usual result of this fracture. 

The fragments, more or less displaced, undergo various changes. 
The acetabular fragment is generally rapidly absorbed as far as the 
head ; and occasionally a considerable portion of this latter disappears 
also ; while the trochanteric fragment appears rather as if it had been 
flattened out by pressure and friction, it having gained as much gene- 
rally in thickness as it has lost in length. To this observation, however, 
there will be found many exceptions. Sometimes the trochanteric frag- 
ment forms an open, shallow socket, into which the acetabular fragment 
is received ; or its extremity may be irregularly convex and concave, to 
correspond with an exactlv opposite condition of the acetabular fragment. 
(Fig. 132.) 

Ordinarily the two fragments move upon each other, without the 
intervention of any substance ; but often they become united, more or 
less completely, by fibrous bands (Fig. 133), which bands may be short 
or long, according to the amount of motion which has been maintained 



414 



FKACTURES OF THE FEMUR. 



between the fragments while they are forming, or to the degree of sepa- 
ration which exists. 

The capsular ligaments are usually considerably thickened, and elon- 
gated in certain directions, and not unfrequently penetrated by spicula 
of bone. They are also found sometimes attached by firm bands to the 
acetabular fragment. 

A permanent shortening is the invariable result of this accident ; and not 
a few succumb rapidly to the injury, perishing from a low, irritative fever, 



Fig. 132. 



Fig. 133. 





Fracture of cervix femoris within capsule. 
Ununited. Opposite surfaces irregularly con- 
vex and concave, and polished ; moving 
slightly upon each other. (From a specimen 
in the possession of Dr. Josiah Crosby.) 



Mayo's specimen. United by ligament. Patient 
lived nine months after the accident. The trochan- 
ter minor arrested the descent of the head. (From 
Sir A. Cooper.) 



or from gradual exhaustion, within a month or two from the time of its 
occurrence. Says Robert Smith : " Our prognosis, in cases of fracture 
of the neck of the femur, must always be unfavorable. In many in- 
stances the injury soon proves fatal, and in all the functions of the limb 
are forever impaired ; no matter whether the fracture has taken place 
within or external to the capsule — whether it has united by ligament or 
bone — shortening of the limb and lameness are the inevitable results." 

Dr. Frederick E. Hyde, of this city, has made a very careful exami- 
nation of twenty cases of fracture of the neck of the femur, after seve- 
ral years from the date of the fracture. Thirteen of these had been 
diagnosticated as intracapsular, and seven as extracapsular. All were 
shortened ; the shortening ranging from three-eighths of an inch to two 
and a quarter inches in the intracapsular fractures ; and from one-quar- 
ter to one and a half inches in the extracapsular. 

Some of the cases had never been treated by apparatus of any kind, and 
it was observed that, omitting one case in which the contracted position 
of the limb did not permit an accurate measurement, the average shorten- 



415 

ing was one and three-eighths of an inch ; while in those which had been 
treated as fractures, the average shortening was about one inch. All, 
or nearly all of them were still suffering with more or less pain and stiff- 
ness about the joint, and walked with a manifest halt. 1 

Treatment. — In case, then, of a complete fracture within the capsule, 
existing without laceration of the reflected capsule, or displacement of 
the fragments, and equally in case of a fracture at the same point with 
impaction, the treatment ought to be directed to the retention of the bone 
in place, by suitable mechanical means, for a length of time sufficient to 
insure bony union, or for so long a time as the condition of the patient 
will warrant. 

Fig. 134. 




Author's apparatus for fractures of the neck of the femur. 

The means which are, in my judgment, best calculated to fulfil this im- 
portant indication, are complete rest in the horizontal posture, the limb 
being secured by the same apparatus which we employ with so much suc- 
cess in fractures of the shaft. In fractures of the neck, however, whether 
within or without the capsule, we employ no coaptation splints ; and the 
amount of extension ought to be only one-half of that generally employed 
in fracture of the shaft, say about ten pounds. The long side-splint, 
with a foot-board, to prevent eversion of the limb, must not be omitted. 
In my hands, the apparatus has undergone so many modifications from 
the original plans of Crosby and Buck, that I shall hereafter find it 
necessary to designate it as my own. 

Fig. 135. 




Gibson's modification of Hagedorn's splint. 



Another apparatus, formerly employed by me in fractures of the neck 
of the femur, but for which I have substituted my own, is Gibson's modi- 



1 Hyde, Deformity after Fracture of the Neck of the Femur ; 20 cases, arranged and 
tabulated. Med. Gazette, April 17, 1880, p. 244. 



416 FRACTURES OF THE FEMUR. 

fication of Hagedorn's, in which the sound limb is first secured to the 
foot-board, and the broken limb is subsequently brought down to the 
same point. By this method, as by my own apparatus, w T e may avoid 
the necessity of a perineal band, which is so painful, insupportable often 
when the fracture is at the neck. 

In treating this fracture, supposing no displacement to exist, no exten- 
sion beyond that which is necessary to insure perfect quiet can be proper, 
inasmuch as the fragments are not overlapped ; and they need only a 
moderate assistance to enable them to maintain their present position 
against the action of the muscles. Moreover, if the fragments are im- 
pacted, violent extension would disengage them, and render their displace- 
ment and non-union inevitable. 

I am prepared to affirm, from my own experience, that more patients 
will endure quietly the position of extension for a length of time than the 
flexed position, whether in this latter the patient is placed upon his side 
or upon his back. 

Fig. 136. 




Gibson's modified splint applied. 

How long the patient will submit to this, or to any other mode of 
securing perfect rest, is very uncertain, and the decision of this question 
must rest with the individual cases and the good sense of the surgeon. 
Not very many old and feeble people will bear such confinement many 
days without presenting such palpable signs of failure as to demand their 
complete abandonment. 

Horizontal extension w T as adopted in Jones's case, and also in the case 
reported by Fawdington, and is said to have been successful. In Brula- 
tour's case the limb was kept extended two months ; in Mussey's second 
case Hartshorne's straight splint for extension remained upon the limb 
eighty-four days ; in Bryant's case a long splint was used " some weeks." 

It is true, however, that other plans of treatment seem to have been 
equally successful. In the case reported by Adams the limb was placed 
over a double-inclined plane, made of pillows, five weeks ; and in Mus- 
sey's third example the limb remained in the same position three months. 
Chorley laid his patient upon the sound side, with the thighs flexed, for 
a space of two weeks, and then turned him upon his back, still keeping 
the thighs flexed. At the end of six weeks he was placed in a straight 
position. 

But in a majority of the examples reported, the existence of the frac- 
ture was either not suspected, or bony union Avas not anticipated or de- 
sired, consequently no treatment having in view the confinement of the 
broken bone was adopted. Yet the success, it was claimed, was as great 



THE CAPSULE. 417 

as that which has followed either of the other plans. Harris's patient 
was simply laid on a sofa. Field's patient, who broke the neck of both 
femurs within the capsule at different times, was in each case left with- 
out treatment, except that she lay upon her bed. Mussey himself re- 
moved all dressings from Dr. Dalton's patient on the eighteenth day, and 
placed him upon his feet, and Dr. Wakelee removed the apparatus from 
his mother on the fifth clay. 

Nor are we without evidence that the careful and judicious applica- 
tion of splints, long continued, and employed under the most favorable 
circumstances, will sometimes fail. The two following cases confirm 
these remarks. The first occurred in the practice of Dr. James R. 
"Wood, of this city : " M. J., a young lady, get. 16 years, of vigorous 
constitution, perfectly free from any constitutional taint, either of scrofula, 
syphilis, or cancer, was caught between the wheels of two carriages, the 
one stationary, the other in motion. The blow was received directly on 
the trochanter major of the right side. The symptoms which presented 
themselves showed conclusively that there was a fracture. There was 
shortening, loss of voluntary motion, and eversion ; by placing the finger 
on the trochanter major, and the thumb on the groin, a well-marked 
crepitus could be felt on extension and rotation being made. There was 
no laceration or other complication of the injury. She was placed on 
Amesbury's splint, with side splints accurately adjusted, and every pre- 
caution taken to insure a perfect union. The limb was kept on this 
splint without being disturbed for six weeks. At the end of that time 
it was taken from the splint, and examined with care ; the signs of frac- 
ture still remained. The limb was replaced on the splint, and the dress- 
ings applied as before ; everything was attended to in the general manage- 
ment of the case which the doctor thought would be conducive to perfect 
union. The patient was kept for three weeks longer on the splint, 
which was then removed. It was found that there was no union. Pa- 
tient lived for three years, and was so lame that she was always obliged 
to use a crutch in walking. At the expiration of three years she died 
of an acute disease. 

" On examination of the cervix femoris, it was found that there had 
been a transverse fracture of the bone just at the junction of the head 
and neck. The head of the bone was still attached to the acetabulum 
by the ligamentum teres. The process of absorption had been going 
on, and the head of the bone had already been absorbed below the level 
of the acetabulum, and what remained was soft and spongy, easily broken 
with the handle of the scapel. The neck of the bone was rounded off, 
and covered with a fibrous deposit. This was not a case of diastasis, as 
has been suggested by an eminent surgeon, who judged simply from the 
age of the patient. She was full sixteen when the accident happened, 
and over nineteen when she died." 

The second was in the person of a man, aet. 25 years, who was at the 
time of the accident robust and in good health. " He was dancing at 
his sister's wedding ; while cutting a pigeon wing, he struck the foot 
upon which he was resting from under him, and fell, striking directly 
upon the trochanter major. He was unable to rise ; a carriage was 
called, and he was taken directly to the New York Hospital. There he 



418 FRACTURES OF THE FEMUR. 

came under the charge of Dr. J. Kearney Rodgers. A fracture was 
immediately diagnosticated, and for a few days he was kept on the 
double-inclined plane. The straight splint was then used, and the dress- 
ings kept up for six weeks ; at the end of that time they were taken off, 
and the limb examined ; there was no union. The limb was continued 
in the straight splints for three weeks longer, and again examined ; there 
was still no union. The patient was again replaced in the straight splint 
for two weeks longer, but no union occurred. At the end of three 
months from his admission he was discharged ; he was in good health, 
but so lame that he was obliged to use two crutches in walking. After 
his discharge the patient became very intemperate ; and in the course 
of a few weeks he applied for admission to Belle vue Hospital. He was 
much debilitated, and had an exhausting diarrhoea. Shortly after his 
admission an immense abscess formed over the joint, which discharged 
profusely. The man died shortly after from exhaustion, and the speci- 
men came into Dr. Van Buren's hands, the patient having been in his 
service. Dr. Van Buren was aware of the patient's previous history, 
the treatment, etc., at the New York Hospital, and a careful examina- 
tion was made. 

" The capsular ligament was destroyed entirely by the suppurative 
process ; there was a formation of callus upon the trochanter major; the 
ligamentum teres was entirely absorbed ; the head of the bone was spongy, 
as if worm-eaten ; the direction of the fracture was oblique, commenc- 
ing just at the articulating surface of the head and ending just within 
the capsule ; the upper end of the shaft of the bone showed this same 
appearance that was marked in the head. These points are beautifully 
shown in the specimen at the present time. The opinion of Charles E. 
Isaacs, M.D., the able Demonstrator of Anatomy of the University 
Medical College, is, that this fracture was entirely within the capsule." 1 

Such equal results from opposite plans, and unequal results from simi- 
lar plans of treatment, are not calculated to increase our faith in the testi- 
mony which most of the foregoing examples are supposed to furnish of 
the possibility of bony union. On the contrary, they cannot fail to sug- 
gest a doubt as to whether some of them, at least, were not inaccurately 
diagnosticated. 

But admitting that they were not, the testimony which they furnish in 
relation to treatment is too inconclusive to be made available for instruc- 
tion, and we are still at liberty to adopt that which seems most rational, 
without reference to the experience of others. 

The reasons why I would prefer my own plan have already been, stated 
in part, to which I will now add, that if an error should occur in the 
diagnosis — if it should prove finally to have been a fracture without the 
capsule — then this treatment would be correct, and no injury would come 
to the patient from the error in diagnosis ; but if we adopt Sir Astley 
Cooper's suggestion, namely, to get the patient upon crutches as soon as 
possible, perhaps as soon as fourteen days, an error in diagnosis might 
be followed by the most disastrous consequences. 

In gunshot intracapsular fractures, if suppuration ensues, the head of 

1 Johnson, op. cit , pp. 13-15. 



NECK, WITHOUT THE CAPSULE. 419 

the bone and other fragments ought to be removed ; and there may occur 
cases in which the fragments should be removed immediately, as has been 
done occasionally with satisfactory results. So, also, if after a simple 
intracapsular fracture, suppuration within the joint were to ensue, resec- 
tion would be the proper resort : but I cannot agree with Dr. Howe in 
his report of a case to the New York Academy of Medicine, that, in all 
cases of intracapsular fractures of the neck of the femur, occurring in 
persons who were not very decrepit or exhausted, and where crepitus 
was well marked, at the end of three months of careful treatment, and 
the patient confined to bed, the operation of excision should be performed 
without delay. 1 The probabilities seem to be that in most or all of 
these cases the patient is likely to have as useful a limb without excision 
as with, and if so, the hazards of the operation, however trivial, must 
decide the question against its performance. In the case operated upon 
by Dr. Howe, the result is by no means encouraging, and it is apparent 
that the limb was not judiciously managei before the operation. It was 
kept too long in splints. 

(b) Neck of the Femur without the Capsule. 

Causes. — Like fractures within the capsule, these also occur most fre- 
quently in advanced life. They are not, however, as often met with in 
extreme old age as are fractures within the capsule ; and they are much 
more often met with in persons of middle age, and in younger persons, 
than are intracapsular fractures. Of fractures recognized as extracap- 
sular, in Dr. Hyde's tables, ten were under fifty years, and seven at or 
over fifty. The three youngest were respectively thirty, twenty-five, 
and twenty years of age. Of the 42 recorded by me as extracapsular 
fractures I have made no careful tabulation of the ages, but it is certain 
that in general they belong to a younger class of persons than the cases 
recorded as intracapsular. 

As to the immediate causes, we have already mentioned in the pre- 
ceding section that fractures without the capsule seem to be the result 
generally of falls or of blows received directly upon the trochanter ; 
occasionally, also, they are produced by falls upon the feet or upon the 
knees. 

Pathology. — These fractures may occur at any point external to the 
capsule, but generally the line of fracture is at the base, corresponding 
very nearly with the anterior and posterior intertrochanteric crests. 
Almost invariably the acetabular penetrates the trochanteric fragment 
in such a manner as to split the latter into two or more pieces. The di- 
rection of the lesions in the outer fragments preserves also a remarkable 
uniformity ; the trochanter major being usually divided from near the 
centre of its summit, obliquely downwards and forwards toward its base, 
and the line of fracture terminating a little short of the trochanter minor, 
or penetrating beneath its base ; while one or two lines of fracture usually 
traverse the trochanter major horizontally. 

1 J. W. Howe, M.D., Hospital Gazette, Dec. 20, 1879, p. 660; also the Debate, p. 
665, in which other similar operations are cited. 



420 FRACTURES OF THE FEMUR. 

In an examination of more than thirty specimens, I have noticed but 
two or three exceptions to the general rules above stated. 

In Dr. Mutter's collection, specimen marked B 115 is not accompanied 
with either impaction or splitting of the trochanteric fragment ; but the 
neck having been broken close to the intertrochanteric lines, has, appa- 
rently, slid down upon the shaft about one inch, at which point it is firmly 
united by bone. 

Dr. Neill has also a specimen of fracture at the same point, but with- 
out union of any kind, in which no traces remain of a fracture of the 
trochanters. The acetabular fragment has moved up and down upon the 
trochanteric until it has worn for itself a shallow socket three inches and 
a half long ; the approximate surfaces being smooth and polished like 
ivory. 

The trochanter major is usually turned backwards, the shaft of the 
femur being rotated in this direction, the same as is usually observed in 
other fractures of the neck of the femur. I have seen one exception to 
this general rule in a specimen belonging to Dr. Mutter (No. 29); the 
trochanter in this instance is turned forwards, so that the neck is shorter 
in front than behind. 

The upper fragments of the trochanter major, whenever the lines of 
fracture are transverse, are generally inclined inwards toward the neck, 
as if displaced in this direction by the force of the blow, or perhaps by 
the resistance offered by certain muscles and ligamentous bands which 
find an insertion upon its summit. 

The neck is found, in most cases, standing inwards at nearly a right 
angle with the shaft, the head being much more depressed than the outer 
extremity of the neck ; in consequence of which the lower margin of its 
broken extremity is driven much deeper into the trochanteric fragment 
than is the upper margin. 

Malgaigne believes that impaction, with consequent fracture of the 
trochanters, is never absent in true extracapsular fractures, unless it be 
in that very unusual variety in which the trochanter forms a part of the 
inner fragment (fractures through the trochanter major and base of the 
neck). Robert Smith entertains the same opinion, although Malgaigne 
does not seem to have so understood him. I cannot agree, however, with 
either of these gentlemen that the rule is so invariable, since I am con- 
fident that no such splitting has occurred in either of the two specimens 
to which I have referred as belonging respectively to Drs. Mutter and 
Neill. It is true these are both old fractures, and to some extent the 
signs of fracture may have become obliterated, but in Mutter's specimen 
an abundant callus indicates plainly enough where the shaft separated 
from the neck, while the trochanter major is smooth as in its normal con- 
dition, nor does its summit incline either way from its usual position. 
ISTeill's specimen, though less satisfactory, does not fail to convince me 
that neither impaction nor splitting of the trochanters ever occurred. 

It is certain, however, that impaction and comminution of the outer 
fragment are very constant, and that, whether the fracture is produced 
by a fall upon the feet or upon the trochanter major. But the impac- 
tion does not necessarily continue ; sometimes, indeed, it does, and the 
position of the limb, whatever it may be at the moment, remains un- 



NECK, WITHOUT THE CAPSULE. 



421 



alterably fixed ; either very little or considerably shortened, according 
to the degree of impaction ; rotated outwards or inwards, or in neither 
direction, perhaps, according to the direction of the force and the 
amount of comminution. In other cases, owing to the extreme com- 
minution, and to the wide separation of the trochanteric fragments, or 
to the contraction of the muscles inserted into the top of the femur, or 



Fig. 137. 



Fig. 138. 



Fig. 139. 




Impacted extracapsular fractures. (R. Smith, and Erichsen.) 



to the weight of the body in attempts to walk, or to injudicious hand- 
ling on the part of the surgeon, such as forcible rotation, by which the 
neck is made to act as a lever, and to actually pry the fragments apart, 
or to violent extension, by which the impaction is overcome — owing to 
some one or several of these causes it often happens that the fragments 
separate, and the leg becomes immediately more shortened, movable, 
and more inclined to rotate outwards. 

Symptoms. — The symptoms which indicate a fracture of the neck of 
the femur without the capsule, are pain, mobility, crepitus, shortening, 
and eversion of the limb. The trochanter major is not as prominent 
as upon the opposite side ; and, especially where the fragments are not 
impacted, but are completely separated, it rotates upon a shorter axis. 
There are also several other signs to which I shall refer when consider- 
ing the differential diagnosis. 

Before considering more in detail the value of these several signs, I 
wish to call attention to a fact which has been often observed by myself 
and others, namely, that the patient is able, sometimes, immediately 
after this accident, to take a few steps ; yet never, perhaps, without 
considerable pain. The same may happen in an intracapsular impacted 
fracture, but it happens much more often in the extracapsular impacted 
fracture ; but the following case is the most remarkable, in this point of 
view, of any which has come under my notice : A laboring man, about 
50 years of age, presented himself at my clinic at Belle vue Hospital, 
some time during the fall of 1874, who stated that two years before he 



422 FRACTURES OF THE FEMUR. 

had fallen a distance of nine feet, striking upon his side ; that after a 
little he arose, and, with the aid of a stick, walked a mile or more to 
his home. Walking caused great pain in his hip, and he was much 
exhausted when he reached home, and went to bed ; but, having no 
suspicion that his limb was broken, he did not call a surgeon. Within 
a fortnight from this time he bagan to walk about, and a week later he 
began to perform ordinary labor, yet not without pain. 

When this man came before the class I found the limb shortened 
three-quarters of an inch, the toes everted, the trochanter major de- 
pressed — that is, flattened — irregular in form, and much increased in 
breadth. He is a man of intelligence, and is certain that these changes 
of form, etc., were observed by him very soon after his recovery. It 
seems proper, therefore, to assume that this was not an example of 
gradual change of form and position due to a chronic ostitis, but that it 
was an extracapsular fracture. 1 

The pain and tenderness, accompanied sometimes with swelling and 
discoloration, are situated most often in front of the neck of the bone. 

Mobility exists in a majority of cases, even when the fragments are 
impacted ; that is, the limb can be moved pretty easily in any direction 
by the surgeon, but not without producing pain or provoking muscular 
spasms, yet the patient himself is unable to move the limb by his own 
volition, or he can only move it slightly. 

Crepitus is present whenever there exists a moderate but not com- 
plete impaction. It is also present generally when, the trochanteric 
fragment having been extensively comminuted and loosened, the im- 
paction becomes excessive ; and it is only absent when the impaction 
is such that the fragments are completely and firmly locked into each 
other. 

A shortening is inevitable, at least in all cases accompanied with' 
either temporary or permanent impaction, and we have seen that one 
of these conditions seldom fails. According to Sir Astley Cooper the 
shortening varies from half an inch to three-quarters of an inch, but 
Robert Smith has established the following distinction. When the frac- 
ture is extracapsular and impacted, that is, when it remains impacted, 
the shortening is only moderate, varying from one-quarter of an inch to 
one inch and a half ; in fourteen cases measured by him the average was 
a fraction over three-quarters of an inch ; but when it does not remain 
impacted it ranges from one inch to two inches and a half; indeed, Mr. 
Smith mentions one example in which the shortening reached four inches, 
and forty-two cases gave an average shortening of something more than 
one inch and a quarter. Mr. Smith's experience as to the average 
amount of shortening in these cases agrees very nearly with my own. 

Eversion of the toes is very constant ; but in a few instances upon 
record the toes have been found turned in, or even directed forwards. 
During the winters of 1864 and 1865, I found a case of this kind in my 
wards at Belle vue Hospital. In the specimen referred to as being 



1 Canton on Interstitial Absorption of the Neck of the Femur from Bruise, etc. 
London Med. Gazette, Aug. 11, 1848. 



NECK, WITHOUT THE CAPSULE. 



423 



fouud in Dr. Mutter's collection, with an in- Fig. 140. 

ward or forward rotation of the trochanter 

major, the same relative position of the whole 

limb must have existed ; and in my remarks 

on fractures of the neck within the capsule, 

I have referred to several examples, some of 

which were probably extracapsular. 

The trochanter major usually seems de- 
pressed or driven in ; and when the two main 
fragments are completely separated, if the 
limb is rotated, the trochanter will be found 
to turn almost upon its own axis, or upon a 
very short radius. 

In enumerating the signs of a recent extra- 
capsular fracture, it will be seen that I have, 
with only slight variations, repeated the signs 
of a fracture within the capsule. It will be- 
come necessary, therefore, to indicate, as far 
as possible, a differential diagnosis. And 
without pretending that all of the differential 
signs which I shall enumerate are thoroughly 
established, or that in every case, even after Fractui 
a careful grouping of all the symptoms, a 
satisfactory diagnosis can be made out, I shall state briefly my own 
elusions, or rather what seem to me to be the probable facts. 




of the neck of the 
(Fergusson.) 



con- 



SlGNS OF A FRACTURE WITHIN THE CAPSULE. 

Produced often by slight violence. 
. A fall upon the foot or knee, or a trip 
upon the carpet, etc 

Generally over fifty years of age. 

More frequently in females. 

Pain, tenderness, and swelling less and 
deeper. 



Ecchymosis not often seen. 

(The two following measurements to 
be made from the lower margin of the an- 
terior superior spinous process of the ilium 
to the lower extremity of the malleolus 
externus or internus.) 

Shortening at first less than in extra- 
capsular fractures, often not any. 

Shortening after a few days or weeks 
greater than in extracapsular fractures. 
Sometimes this takes place suddenly, as 
when the limb is moved, or the patient 
steps upon it. 

Measuring from the top of the tro- 
chanter to the condyles or to the malleoli, 
the limb is not shortened. 



Signs of a fracture without the capsule. 

Produced usually by greater violence. 
A fall upon the trochanter major. 

Often under fifty years of age. 

Relative frequency in males or females 
not established. 

Pain, swelling, and tenderness greater 
and more superficial. It is especially 
painful to press upon and around the 
trochanter major. 

Superficial and extensive ecchymosis 
quite frequent. 



Shortening at first greater, almost al- 
ways some. 

Shortening after a few days or weeks 
less than in intracapsular fractures, pro- 
vided proper extension has been main- 
tained. That is, the amount of shortening 
changes but little, if at all ; if the inrpac- 
tion continues, not at all ; if it does not 
continue, it may shorten more. 

Measuring from the top of the tro- 
chanter to the condyles or to the malleoli, 
the limb may be found a little shortened. 



424 



FRACTURES OF THE FEMUR. 



Signs of a fracture within the capsule 
{continued). 

Trochanter major moves upon a rela- 
tively longer radius than in cases of 
extracapsular fractures, the pivot being 
nearer the acetabulum. 

If the patient recovers the use of the 
limb, not restored under many months, 
or years. 

No enlargement or apparent expansion 
of the trochanter major, after recovery, 
from deposit of bony callus. 



Progressive wasting of the limb for 
many months after recovery. 

Excessive halting, accompanied with a 
peculiar motion of the pelvis, such as is 
exhibited in persons who walk with an 
artificial limb. 



Signs of a fracture without the capsule 
(continued). 

Trochanter major moves upon a rela- 
tively shorter radius, the pivot being 
more remote from the acetabulum. 

The patient recovers the use of the limb 
sooner. 

Enlargement or irregular expansion of 
trochanter, which may be felt sometimes 
distinctly through the skin and muscles, 
and which is especially manifest after the 
lapse of some months. 

The limb preserving more nearly its 
natural strength and size. 

Comparatively slight halt, motions of 
hip more natural. 



Prognosis. 1 — In attempting to establish the differential diagnosis, we 
have necessarily been led to consider most of the essential points of 
prognosis. Very little, therefore, remains to be said upon this subject. 

Union occurs as rapidly in this fracture as in fractures of the shaft ; 
and perhaps in general more promptly, owing to the existence of im- 
paction. 



Fig. 141. 



Fig. 142. 





Extracapsular fracture. (Erichsen.) 



Extracapsular fracture. (R. Smith.) 



But whether it occurs promptly or slowly, or, indeed if it does not 
occur at all, a remarkable deposit of ossific matter almost invariably 
takes place along the intertrochanteric lines, where the bone has sepa- 
rated from the shaft, and also, not unfrequently, along the lines of the 
other fractures of the trochanter. 



1 See observations of Dr. Frederick E. Hyde in preceding section. 



NECK, WITHOUT THE CAPSULE. 425 

This deposit is no less remarkable for its abundance than for its 
irregularity, long spines of bone often rising up toward the pelvis and 
forming a kind of nobby or spiculated crown, within which the acetabular 
fragment reposes. In a few instances these osteophytes have reached 
even to the bones of the pelvis, and formed powerful abutments, which 
seemed to prevent any farther displacement of the limb in this direction, 
and by some writers they have been supposed thus to fulfil a positive 
design. A sufficient explanation of their existence, however, we think, 
can be found in the fact that they proceed entirely from the trochanteric 
fragments, whose extensive comminution and great vascularity would 
naturally lead to such results. The same, but in a less degree, has 
already been noticed as occurring in impacted fractures at the anatomi- 
cal neck of the humerus, where certainly such bony abutments could not 
serve any useful purpose. « 

Probably in all, certainly in nearly all cases, the limb will be found, 
after the union is consummated, more or less shortened, generally between 
half an inch and an inch. If exceptions ever occur it must be in those 
examples in which there is no impaction, and it is certain that such 
examples are very rare. Such is the united testimony of all surgeons 
whose opinions have ever been respected as authority ; and the same is 
true of intracapsular fractures. What ignorance of the elementary facts 
of surgical science do these men exhibit, then, who affirm that they are 
able to treat all fractures of the femur without shortening. 

Eversion of the foot is not so constant as shortening, but it will be 
found to exist in some degree in a large majority of cases, even when the 
case has been managed in the most skilful manner ; yet in this regard 
something will depend upon the position in which the limb is maintained 
during the treatment. 

Treatment. — The same principles of treatment are applicable here as 
in fractures of the neck within the capsule ; by which I mean to say 
that, as in all of those examples of fracture within the capsule where 
the relation of the fragments is such as to warrant a hope that a bony 
union may be consummated, namely, where the fragments are not dis- 
placed or are impacted, the straight position, with only moderate ex- 
tension, constitutes the most rational mode of treatment ; so also in this 
fracture, whenever the fragments are impacted and remain impacted, 
the straight position, with moderate extension, employed only as a 
means of retention, but not so as to overcome impaction, is the most 
suitable. It is only by employing this plan of treatment, which no one 
has yet shown to be inapplicable to either of these two varieties of ac- 
cidents — I do not speak of the opinions which men may have enter- 
tained, but of the practical testimony — it is only, I say, by employing 
this uniform plan of treatment in both cases, that those serious misfor- 
tunes to the patient can be avoided which would necessarily continue to 
occur if Sir Astley Cooper's advice were followed, namely, to allow the 
patient in the one case to dispense with splints wholly, and to get upon 
his crutches as soon as the condition of his limb and of his body will 
permit, when it is certain that in the other case some retentive apparatus 
is generally necessary. This conclusion is based upon the admitted 
difficulty of diagnosis. If, as is well understood, the diagnosis between 
28 



426 



FRACTURES OF THE FEMUR. 



Fig. 143. 



these two varieties of fracture is often impossible during the life of the 
patient, then how shall we know in any given case which of the two 
plans to adopt ? If we act upon the supposition that it is within the 
capsule, adopting Sir Astley Cooper's method, and it proves to have 

been a fracture without the capsule, we 
may do irreparable injury to our patient. 
It is precisely here that this distinguished 
surgeon committed his great error ; not in 
denying that certain specimens were frac- 
tures of the neck of the femur within the 
capsule united by bone, nor in constantly 
urging upon his contemporaries the impro- 
bability of such an event ; but in that, while 
he admitted its possibility, he chose to 
recommend a plan of treatment which was 
unlikely to insure such a union, and which, 
in the uncertainty, if not impossibility, of 
diagnosis, was liable, upon his supposed 
authority, to be adopted in many cases of 
extracapsular fractures. 
Again, if the fracture be extracapsular and not impacted, or the im- 
paction has been, for any cause, overcome ; or, if the fracture be intra- 
capsular and not impacted, or if the capsule is lacerated and the frag- 
ments are in consequence displaced ; then again no injury need result 
from the treatment, if we adopt the straight position with moderate ex- 
tension, such as may be obtained from the use of my apparatus. That 
it is or is not impacted we may know generally, by the amount of dis- 
placement, although we may not easily decide whether the fracture is 
within or without the capsule. Now, the amount of shortening will 
determine properly enough the amount of extension to be employed. 




Extracapsular fracture. 



Fig. 144. 




Miller's splint for extracapsular fracture. (From Miller 



In either case, however, we shall not employ as much extension as in 
fractures of the shaft ; and while if it be an intracapsular fracture we 
may only gain a shorter and firmer ligamentous union, if it proves to be 
extracapsular we shall insure a better and more speedy bony union. 

If any surgeon, acting upon the suggestions here made, shall confine 
a feeble or an aged person in the horizontal posture, with or without a 
straight splint, until the powers of nature have become exhausted, and 



THROUGH THE TROCHANTER MAJOR. 427 

death ensues, as our readers have already been admonished may happen, 
we are not to be held responsible for his want of judgment or of skill. 
We have advised this plan of treatment only for so long a period as 
the condition of the patient renders it entirely safe, or as it can prove 
useful. No doubt, then, in a large number of cases, it will have to be 
abandoned very early, and in not an inconsiderable proportion all con- 
straint will be plainly inadmissible from the beginning ; and it is for 
such examples that the treatment recommended by Sir Astley Cooper 
for all intracapsular fractures ought to be reserved. 1 

(c) Fractures of tlie Neck partly within and partly without the Capsule. 

It is scarcely necessary to say that the line of fracture through the 
neck of the femur may be such, that it shall be in part within and in part 
without the capsule ; and such fractures will be even more difficult to 
diagnosticate than either of those forms of which we have just spoken. 
The symptoms will be mainly, however, those which characterize frac- 
tures within the capsule, while the treatment ought to be such as we 
would adopt in those fractures which are wholly without the capsule. 
The chances for bony union are increased in proportion as the line of 
separation extends outside of the capsule, and we ought to be diligent 
in our efforts, if we have made ourselves certain that the fracture is partly 
extracapsular, to secure a good bony union ; a result which experience 
has shown may be reasonably anticipated. 

The necessity for some extension, and of firm retentive apparatus in 
this form of fracture, furnishes another argument in favor of the employ- 
ment of the same means in fractures wholly within the capsule. We 
shall thus avoid the mischief which might arise from mistaking a fracture 
of the character of which we are now speaking, for a fracture wholly 
within the capsule. 

§ 2. Fracture through the Trochanter Major and Base of the Neck 
of the Femur. 

This fracture, which Sir Astley Cooper calls a fracture of the "femur 
through the trochanter major," 2 passes obliquely upwards and outwards 
from the lower portion of the neck, but instead of traversing the neck 
completely, it penetrates the base of the trochanter major ; the line of 
fracture being such as to separate the femur into two fragments, one of 
which is composed of the head, neck, and trochanter major, and the other 
of the shaft with the remaining portions of the femur. 

The following two examples are all in relation to which we possess 
any positive information, or in which the diagnosis has been confirmed 
by an autopsy. The first is thus related by Sir Astley Cooper. 

" The first case of this kind I ever saw was in St. Thomas's Hospital, 
about the year 1786. It was supposed to be a fracture of the neck of 

1 Fracture of the Neck of the Femur. Clinical Lecture at the Bellevue Hosp., by 
the Author. Priority in Employment of Extension, etc. The Medical Record, March 
9, 1878. 

2 Sir Astley Cooper, op. cit., p. 183. 



428 FRACTURES OF THE FEMUR. 

the thigh-bone within the capsule, and the limb was extended over a 
pilloAv rolled under the knee, with splints on each side of the limb, by 
Mr. Cline's direction. An ossific union succeeded, with scarcely any 
deformity, except that the foot was somewhat everted, and the man walked 
extremely well. When he was to be discharged from the hospital, a 
fever attacked him, of which he died ; and, upon dissection, the fracture 
was found through the trochanter major, and the bone was united with 
very little deformity, so that his limb would have been equally useful as 
before." 1 

The second example is reported by Mr. Stanley. 

"A woman, in her sixtieth year, fell in the street and injured her 
right hip. On examination, the limb was found slightly everted, and 
shortened to the extent of three-quarters of an inch, but movable in 
every direction. The extremity of the shaft of the femur w.as in its 
natural situation ; but behind the femur, and at a little distance from it, 
a bony prominence was discovered, resting upon the ilium, toward the 
great sciatic notch, strongly resembling the head of the femur. Various 
opinions were entertained as to the nature of the injury, some believing 
it to be dislocation, and others a fracture. After a confinement of several 
months to her bed, the woman was sufficiently recovered to walk with the 
assistance of a crutch, and in this state she continued till her death, 
which took place about three years after the accident, during the whole 
of which period I had watched the progress of the case. Having obtained 
permission to examine the seat of the injury, T ascertained that there 
had been a fracture extending obliquely through the trochanter major, 
and through the basis of the neck into the shaft of the femur, and that 
the prominence which had been mistaken for the head of the bone was 
occasioned by the posterior and larger portion of the trochanter drawn 
backwards toward the ischiatic notch." 2 

Sir Astley relates three other examples in which he believes the frac- 
tures to have been of the character above described ; and he details the 
peculiar plans of treatment which, in each case, he saw fit to recom- 
mend. I can see no reason, however, why the treatment need differ 
from that which has already been recommended for fractures of the neck, 
since the indications are nearly identical in all of these cases ; namely, 
moderate extension, and steady support of the limb in its natural position. 

§ 3. Fracture of the Epiphysis of the Trochanter Major. 

So far as I know, the only well-authenticated example of this accident 
is the one reported by Mr. Key to Sir Astley Cooper. 3 The subject of 
this case was a girl, aged about sixteen years, who fell, March 15, 1822, 
upon the sidewalk, and struck her trochanter violently against the curb- 
stone. She arose, and, without much pain or difficulty, walked home. 
On the 20th she was received into Guy's Hospital, and the limb was 
examined by Mr. Key. The right leg, which was the one injured, 
was considerably everted, and appeared to be about half an inch 

1 Op. cit., p. 184. 2 Stanley, Med.-Chir. Trans., vol. xiii. 

3 Sir Astley Cooper on Dislocations and Fractures, etc., Amer. ed., 1851, p. ]92. 




EPIPHYSIS OF THE TROCHANTER MAJOR. 429 

longer than the sound limb. It could be moved Fig. 145. 

in all directions, but abduction gave her consider- 
able pain. She had perfect command over all the 
muscles, except the rotators inwards. No crepitus 
could be detected. Four days after admission she 
died, having succumbed to the irritative fever which 
followed the injury. 

The autopsy disclosed a fracture through the base 
of the trochanter major, but without laceration of 
the tendinous expansions which cover the outside 
of this process, so that no displacement of the epi- p Mr - ^°_ n * ey ', s ™ se - 

1 ' r 1 Prep. 119o, Guy's Mu- 

physis had occurred, nor could it be moved, except seum . (From Bryant.) 
to a small extent upwards and downwards. A con- 
siderable collection of pus was found, also, below and in front of the 
trochanter. 

The absence of displacement in the fragment, with its peculiar and 
limited motion, sufficiently exj)lained why the fracture could not be 
detected during life. 

In the eighth volume of the Transactions of the Medical and Physical 
Society of Calcutta (1825), J. Clarke, Esq., reports a case of comminuted 
fracture of the trochanter major, which has been mentioned by Malgaigne 
as an example of simple fracture of the trochanter ; but, after reading 
the case carefully, I cannot avoid the conclusion that it was an example 
of fracture of the neck without the capsule, accompanied with impaction 
and extensive comminution. " Extravasation," says Mr. Clarke, " was 
discovered within the capsular ligament and around the trochanter major ; 
and, on clearing away the muscles, the trochanter was found crushed and 
shattered, several pieces entirely detached, and fissures extending deeply 
into the shaft of the bone." 1 

I shall venture to express the same opinion in relation to the case 
reported by Bransby Cooper. 2 The diagnosis was not confirmed by an 
autopsy, and the testimony drawn from Mr. Cooper's account of the case 
is far from being, to my mind, conclusive. It may, indeed, have been a 
simple fracture of the epiphysis ; but there is nothing in the narrative 
to render it improbable that there existed also an impacted extracapsular 
fracture of the neck. 

Mr. Poland reports a case, also, which occurred in a boy twelve years 
old, at Guy's Hospital, and which was seen by Mr. Bryant ; but this was 
not confirmed by an autopsy. 3 

I have also myself reported one example of this fracture as having 
come under my own observation, 4 but of which I wish now to speak 
somewhat less confidently. The patient, James Redwick, a travelling 
showman, set. 23, fell, in August, 1848, from a high wagon, striking 
upon his left hip. When he got upon his feet, he found himself unable 
to walk, and was carried to his room. Dr. Wilcox, of Buffalo, was called 

' Clarke, Amer. Journ. Med. Sci., Nov. 1836, vol. ix. p. 181. 

2 B. Cooper, A. Cooper on Dislocations, etc., op. cit., p. 192. 

3 Poland, Bryant's Surgery, 1st ed., p. 950. 

4 Hamilton, Trans. Amer. Med. Assoc, vol. x. p. 254. 



430 



FRACTURES OF THE FEMUR. 



to see him, and applied a long straight splint. Fourteen days after the 
accident I saw the patient with Dr. Wilcox. The thigh was not appre- 
ciably shortened, nor was there either eversion or inversion; but the epi- 
physis of the trochanter major was carried upwards toward the crest of 
the ilium half an inch, and slightly sent in. No crepitus could be de- 
tected. The splint was continued five weeks ; and about a month after, 
I found the fragment in the same place, but he was able to walk with 
only a slight halt. 

I think this also may have been an extracapsular impacted fracture. 

Fig. 146. 




Sir Astley Cooper's mode of treating fractures of the trochanter major. (From A. Cooper.) 

With the small amount of positive information which we possess in rela- 
tion to this fracture, we might venture a few conjectures as to what would 
constitute its symptoms, or as to the probable results and the most suit- 
able treatment ; but we prefer to occupy ourselves with a simple state- 
ment of the facts, so far as they are known, leaving all mere speculative 
inferences to those who choose to make them. 



§ 4. Fractures of the Shaft of the Femur. 

Etiology. — Unless the fracture has taken place just above the con- 
dyles, or immediately below the trochanter minor, in a very large pro- 
portion of cases it has been produced by a direct blow, such as the pas- 
sage of a loaded vehicle across the thigh, or the fall of a piece of timber 
directly upon it. 

Pathology. — It has already been remarked that this bone is most 
frequently broken in its middle third, and usually at a point somewhat 
above the middle of the shaft. I have made the same observation in 
an examination of specimens belonging to Dr. Mutter. In his cabinet, 
of twenty-four fractures of the shaft, three belonged to the upper third, 
two to the lower, and nineteen to the middle third. 

In the adult these fractures are, with only an exceedingly rare excep- 
tion, oblique; and the obliquity is generally greater than in the case of 
other bones. This fact, which it is very difficult to determine, in most 
cases, upon the living subject, I have established by a considerable 
number of observations made upon cabinet specimens. A transverse 
fracture is found only twice in Dr. Mussey's collection, containing 
thirty examples of fracture of the shaft; and in Dr. Mutter's collection, 
specimen B 71 is an adult femur, broken nearly transversely through its 



FRACTUKES OF THE SHAFT OF THE FEMUR. 431 

middle third; and it is united with a shortening of about one inch. 
Indeed, it is more common to find a transverse fracture in the middle 
third than at any other point of the shaft of the bone ; but in the upper 
third the obliquity is extreme and almost constant. 

At whatever point of the shaft the bone is broken, the degree of ob- 
liquity is generally such that the fragments cannot support each other 
when placed in apposition ; unless indeed the fracture is near the con- 
dyles, where the greater breadth of the bone creates an additional sup- 
port ; but even here the cabinet specimens still present a striking 
obliquity, with more or less overlapping. I believe that in each of the 
three specimens of fracture at this point found in the collection belong- 
ing to the Albany Medical College, the obliquity is such that the frag- 
ments were not supported, and an overlapping has taken place. In 
specimen 719 the fracture extends into the joint; and although it is 
united by bone, a shortening of about one inch has occurred. 

In two cases to which I shall hereafter refer, the upper fragment was 
projected through the quadriceps tendon, and became imprisoned under 
the skin. 

In the case of children, and especially of infants, the bone is not un- 
frequently broken transversely or nearly transversely, or it is serrated 
or denticulated, so that complete lateral displacement is much less fre- 
quent. 

The same remark is probably true of a few fractures occurring in 
extreme old age ; but as the shaft of the femur is not often broken in 
very old persons, owing to the readiness with which the neck yields to 
violence, I have not had an opportunity to verify this opinion. 

The direction of the obliquity varies exceedingly, especially in the 
middle and upper thirds ; in the middle third, however, it is generally 
downwards and inwards ; but in the lower third its direction is, with 
only rare exceptions, downwards and forwards, and the superior frag- 
ment is found lying in front of the inferior. 

The direction of the displacement, however, in fractures of the shaft 
of the femur, does not always depend upon the direction of the line of 
fracture. In fractures of the upper third, whatever may be the direc- 
tion of the line of fracture, the lower end of the upper fragment inclines 
forwards and outwards, and the upper end of the lower fragment in- 
wards ; unless, indeed, this inclination is controlled by actual entangle- 
ment of the broken ends with each other. 

In the middle third the fragments also generally take the same rela- 
tive position, whatever may be the direction of the fracture ; but when 
the fracture takes place at or near the condyles, where the diameter of 
the bone is much greater, the direction of the obliquity determines pretty 
uniformly the direction of the displacement. 

Symptoms. — The symptoms which characterize a fracture of the shaft 
of the femur are those which are common to all fractures, namely, mo- 
bility, crepitus, displacement of the fragments, pain, and swelling, to 
which are added generally a shortening of the limb, with eversion of the 
foot and leg. 

Owing to the great amount of muscle covering the thigh, or to the 
swelling which immediately follows the injury, it is sometimes difficult 



432 FRACTURES OF THE FEMUR. 

to determine at what precise point the fracture has occurred ; and it is 
generally still more difficult to say whether the fracture is oblique or 
transverse ; indeed, this latter question is sometimes decided approxi- 
mately by a reference to the age of the patient rather than by the ex- 
amination of the limb. 

The immediate shortening varies from half an inch to an inch and a 
half, or even more ; and it will average about one inch in the case of 
healthy adults. 

Prognosis. — Whatever may have been the general opinion of experi- 
enced surgeons as to the question of shortening in other fractures, very 
few certainly have ever claimed that in fractures of the femur a com- 
plete restoration of the bone to its original length was generally to be 
expected. There seem, however, to have existed only certain vague and 
indefinite notions as to the proportion and amount of this shortening, and 
which have had for their basis nothing better than a few imperfectly 
analyzed observations. 

Says Scultetus (quoting first from Hippocrates) : " 'For the bones of 
the thigh, though you do draw them out by force of extension, cannot be 
held so by any hands ; but when the first intention slacks, they will run 
together again ; for here the thick and strong flesh are above binding, 
and binding cannot keep them down.' — Hippocrates de fract. Which 
Celsus seems to confirm, lib. 8, cap. 10, where he writes as follows of the 
cure of legs and thighs : ' For we must not be ignorant that if the thigh 
be broken, that it will be made shorter, because it never returns to its 
former state.' And Avicenna, lib. 4, fen. 5, saith ' that it is a rare 
thing for the thigh once broken to be perfectly cured again.' 

" These words admonish us," continues Scultetus, " that we should 
never promise a perfect cure of the thigh : but rather, using all dili- 
gence, we should foretell that it is doubtful that the patient will be 
always lame ; but when this shall happen from the nature of the frac- 
ture, or, which most frequently falls out, from the impatience of the sick 
person, it may be imputed to our mistake, and, instead of a reward, 
bring us disgrace." 1 

Says Chelius : " Fracture of the thigh-bone is always a severe acci- 
dent, as the broken ends are retained in proper contact with great diffi- 
culty. The cure takes place most commonly with deformity and short- 
ening of the limb, especially in oblique fractures, and those which occur 
in the upper and lower third of the thigh-bone. Compound fractures 
are so much more difficult to treat." 2 

Says John Bell : " The machine is not yet invented by which a frac- 
tured thigh-bone can be perfectly secured." And Benjamin Bell de- 
clares that " an effectual method of securing oblique fractures in the 
bones of the extremities, and especially of the thigh-bone, is perhaps 
one of the greatest desiderata in modern surgery." " In all ages," he 
adds, "the difficulty of this has been confessedly great; and frequent 

1 The Chirurgeon's Storehouse, by Johannes Scultetus, a Famous Physician and 
Chirurgeon of Ulme in Suevia. London, 1647. 

2 System of Surgery, by J. M. Chelius, translated, etc., by South. First Amer. 
ed., vol. i. p. 627, 1847. See also p. 625, paragraph 679. 



FRACTURES OF THE SHAFT OF THE FEMUR. 433 

lameness, produced by shortened limbs arising from this cause, evidently 
shows that we are still deficient in this branch of practice." 1 

Velpeau says that " after fractures of the femur there is no limping 
unless the shortening exceeds three-quarters of an inch ; and the same 
is true if the shortening occurs in the tibia." The reason is, that the 
pelvis inclines toward the shorter limb, and thus compensates for the 
deficiency in length. In speaking of the various contrivances for dress- 
ing the fractured femur, he remarks that " most of them fail to obviate the 
shortening, and produce eschars, anchylosis, or troublesome arrests of the 
circulation. This is the price that is usually paid for the employment of 
these complicated machines, and a shortening of a quarter to three-quar- 
ters of an inch is not avoided after all. The simplest apparatus that will 
maintain the adjustment of the fractured femur, so that union may take 
place with shortening of only half an inch, is the best." 2 

Nelaton holds the following language : — 

"A fracture of the body of the femur, with an adult, is always a grave 
accident, inasmuch as it demands so long a confinement to the bed, and 
especially on account of the shortening of the limb, which it is almost 
impossible wholly to prevent ; accordingly, Boyer recommends to the 
surgeon, from the first day, to announce to the parents of the patient 
the possibility of this accident. With infants, on the contrary, it is 
almost always easy to avoid the shortening." 3 

While Malgaigne declares his opinion on this subject thus, at 
length : — 

" When we do not succeed in drawing back the misplaced fragments, 
end to end, so that they may oppose themselves to the action of the 
muscles, it is impossible to preserve to the member its normal length, 
whatever may be the appareil or method employed. Surgeons are not 
sufficiently agreed upon this question. 

"At a period quite recent, Desault pretended to cure all fractures 
without shortening, and his journal contains several examples. In imi- 
tation of Desault, various practitioners have modified, corrected, and 
improved the apparatus for permanent extension, and they claim to have 
themselves obtained as complete success. I ought then to declare here, 
in the most positive manner, that I have never obtained like results, 
either in the use of my own apparatus, or with that of others, nor indeed 
where, in pursuance of my invitation, several inventors have applied 
their apparatus in my wards. I have examined, more than once, persons 
declared cured without shortening, and yet, upon measurement, the 
shortening was always manifest. The misfortune of all those who 
believe that they have obtained those miraculous cures is, that they have 
not even thought of instituting a comparative measurement of the two 
limbs ; I will say even more, that they are most generally ignorant of 
the conditions of a good and faithful measurement. Sometimes, also, 
they have been deceived in another way — in falling upon fractures which 

1 System of Surgery, by Benjamin Bell, vol. vii. p. 21. Edinburgh, 1801. 

2 Peninsular Journ. of Med., vol. iii. p. 384; also Memphis Med. Journ., vol. iv. 
p. 254,^ 1856. 

3 Elemens de Pathologie Chirurgicale, par A. Nedaton, torn, prein. p. 752. Paris, 
1844. 



434 FRACTURES OF THE FEMUR. 

were not displaced, especially with young persons; and they have believed 
that they have cured with their apparatus a shortening which had never- 
existed. In short, when the fragments are not displaced, or even when 
they are brought again into contact maintained by their reciprocal den- 
ticulations, it is easy to cure the fracture of the femur without shortening ; 
aside of those two conditions, the thing is simply impossible. 

" Several distinguished surgeons of our day have acknowledged this 
impossibility, and have renounced, in consequence, permanent extension. 
They allege, moreover, that an overriding of even three centimetres is 
of little importance, and occasion no limping. I cannot agree with this 
opinion. I have seen persons walk very well with a shortening of one 
centimetre ; beyond this limit, either they limp, or they have lifted the 
heel of the shoe, or, in short, the limping is only concealed by a lateral 
deviation of the spine. 1 We thus are made to comprehend how a frac- 
ture with overlapping is always serious, and how cautious we ought to 
be in our prognosis." 2 

That the foregoing remarks are intended by the author to be equally 
applicable to other fractures of the shaft of the femur as to those of the 
middle third, is made evident by what he has said before, when speaking 
of fractures of the upper third. 

" The prognosis is sufficiently favorable when the fragments are den- 
ticulated (engrenees) ; when they ride, on the contrary, we must look 
for a shortening as almost inevitable." 3 

In our own country several of the most distinguished surgeons have 
testified to the constant difficulty, if not impossibility, of curing fractures 
of this bone without a shortening. In a suit instituted against a sur- 
geon in New York City, for alleged malpractice in the treatment of an 
oblique, comminuted, and otherwise complicated fracture of the femur 
near its condyles, Dr. Mott is reported to have testified that " more or 
less shortening of the limb is uniformly the result after fractured thigh, 
even in the most favorable circumstances." 4 

In a very interesting communication made to the author by Jonathan 
Knight, of New Haven, late President of the American Medical Asso- 
ciation, occurs the following passage: — 

" I have seen but few fractures of the femur in the adult, unless of 
the most simple kind, in which there was not some remaining deformity; 
often slight, so as not to impair the usefulness of the limb, and in others 
considerable and apparently unavoidable." Dr. Knight adds, however: 
" In the greater proportion of the fractures in children the recovery has 
been so nearly perfect that no marked deformity or lameness has fol- 
lowed." 

Dr. Detmold, in his remarks made before the New York Academy 

1 Dr. Buck, of New York, thinks that with a shortening of one inch, or even one 
inch and a half, the patient may have " a useful limb, with little or no halting in 
his gait." N. Y. Journ. of Med., vol. xvi. p. 294. 

2 Traite des Fractures et des Luxations, par J. M. Malgaigne, torn. prem. pp. 723, 
724. Paris, 1847. 

3 Op. cit. p. 718. 

4 Boston Med. and Surg. Journ., vol. xxxiv. p. 450. See also opinions of Drs. 
Reese, Post, Parker, Cheeseman, Wood, etc., in relation to the prognosis in this par- 
ticular case. 



FRACTURES OF THE SHAFT OF THE FEMUR. 435 

of Medicine, at its meeting in March, 1855, declared his belief that a 
shortening of the femur always occurs after fracture, and that " but one 
inch of shortening in an average of twenty cases is a good result." 1 

Dr. J. Mason Warren, of Boston, writes to me as follows : " As you 
are making observations on fractures, I would state that, after a long 
and very careful observation, I have never yet seen, either in Boston 
or elsewhere, an oblique fracture of the thigh, in a patient over seven- 
teen years of age, in which there was not some shortening. I have had 
cases shown to me in which it was averred that the limb was not 
shortened, but on measuring myself I have found the fact otherwise. 
In children, I believe that union without shortening may be accom- 
plished." 

Dr. Bigelow, of the Massachusetts General Hospital, writes to me, 
May, 1875, as follows : " In our hospital cases shortening is the rule in 
adults. Young subjects do better. Three-quarters of an inch shorten- 
ing in the adult is a good result, and easily compensated by the pelvis. 
Greater shortening may occur." 

In a paper published by Dr. Lente in the number of the New York 
Journal of Medicine for September, 1851, he states that he believes the 
average shortening after treatment in the New York City Hospital to 
be three-quarters of an inch; but subsequently, Dr. Buck, one of the 
hospital surgeons, has furnished Dr. Lente with more exact statistics. 
Says Dr. Buck :— 

" After carefully scrutinizing over one hundred cases of fracture of 
the femur, taken from the register of the New York Hospital, and elimi- 
nating such as involved the cervix, or condyles, or belonged to the class 
of compound fractures, there remained an aggregate of seventy-four 
cases, of both sexes, and of all ages from 3 to 63, in which the shaft of 
the femur alone was fractured." In all these cases the difference in 
the length of the fractured limb, resulting from the treatment, was ascer- 
tained by careful measurement with a graduated tape, and the following 
deductions were drawn from the analysis: — 

" Of the 74 cases of all ages, 19 resulted without any shortening, a 
proportion of about one-fourth. The average shortening of the remain- 
ing 55 cases was a fraction less than three-fourths of an inch. 

" Seventeen cases in the above aggregate were under 12 years of 
age, of which six resulted without any shortening, a proportion of about 
one-third. The average shortening in the remaining eleven cases was a 
fraction less than one-half an inch. 

" Of the 57 cases over 12 years of age, 13 resulted without any 
shortening, a proportion of about one-fourth ; and the average shorten- 
ing in the remaining 44 cases was a fraction over three-fourths of an 
inch." 2 

Mr. Holthouse, surgeon to Westminster Hospital, states that a careful 
examination of fifty cases of fractures of the femur in the various 
London hospitals, made by himself, showed that 90 per cent, (including 
twenty children) were shortened, the amount of shortening ranging 

1 New York Journ. of Med., second series, vol, xvi. p. 261. 
3 Buffalo Med. Journ., vol. xv. p. 22, June, 1859. 



436 FRACTURES OF THE FEMUR. 

from one-half an inch to three and one-third ; and as some of these 
cases were still under treatment, he entertains a doubt whether the final 
result will prove to be as favorable as above stated. For himself he 
declares, with a frankness which is most creditable to his courage and 
honesty, that at Westminster, with all the appliances known to surgery 
at his command, he has never succeeded, in the adult, in effecting union 
without shortening. He has also examined more than one hundred 
specimens in the various museums of the metropolis, and they are all 
shortened. 

After quoting the opinions of several writers upon this subject, includ- 
ing the author of this treatise, Mr. Holthouse adds in a footnote :— 

" Notwithstanding this strong testimony, surgeons are still to be found 
hardy enough, or ignorant enough, to repeat the fallacies which have 
been so often refuted, and to vaunt their success in the cure of oblique 
fractures in the adult without shortening. Why do not these surgeons, 
instead of publishing their cases in the journals, produce their patients 
at some of the medical societies." 1 

It is not to be denied, however, that a few surgeons in all parts of the 
world have claimed, and still continue to claim, in their own practice, or 
from the adoption of their own peculiar plans of treatment, much better 
success. Indeed, some of them do not hesitate to affirm that, as a gen- 
eral rule, any degree of shortening is quite unnecessary. 

Mr. Amesbury declares, that when the fracture is in the " middle or 
lower third," under a "judiciously managed" application of his own 
splint, "consolidation of the bone takes place without the occurrence of 
shortening of the limb, or any other deformity deserving of particular 
notice." 2 

Mr. South, in a note, commenting upon an opposite sentiment ex- 
pressed by Chelius, and already quoted, remarks : " In simple fractures 
of the thigh-bone, except with great obliquity, I have rarely found diffi- 
culty in retaining broken ends in place, and in effecting the union with- 
out deformity, and with very little, and sometimes without any, short- 
ening. For the contrary results the medical attendant is mostly to be 
blamed, as they are usually consequent upon his carelessness or igno- 
rance." 3 

Mr. Hunt, of the Queen's Hospital at Birmingham, who treats all frac- 
tures with the apparatus immobile of Seutin, has published the results of 
his observations ; and of the simple fractures of the femur only one pre- 
sented, after the cure, any degree of shortening ; and he adds that all 
other fractures which he has treated by this method were followed by 
" equally good results." 4 In relation to which statements, Mr. Gamgee 
exclaims : " This is conservative surgery. What other mode of treat- 
ment would have given such results ? And those cases are not excep- 
tional. Mr. Hunt tells us that he has selected them from amongst many 



' Holthouse, Holmes's System of Surgery, 2d ed., 1870, vol. ii. p. 866. 

2 Practical Remarks on Fractures, by Joseph Amesbury, vol. i. p. 384. London ed., 
1831. 

3 Op. cit., vol. i. p. 627. 

4 Researches on Pathological Anatomy and Clinical Surgery, by Joseph Sampson 
Gamgee. London ed., pp. 159, 160. 



FRACTURES OF THE SHAFT OF THE FEMUR. 437 

others equally successful. They accord with the experience recorded in 
my little treatise on this subject ; and the works of Seutin, Burggraeve, 
Crocq, Velpeau, and Salvagnoli Marchetti record numerous cases no less 
remarkable and demonstratively conclusive." 1 

Desault, also, according to the passage from Malgaigne which I have 
already quoted, " pretended to cure all fractures without shortening." I 
do not find, however, any other authority for this statement, as here made ; 
neither in his Treatise on Fractures and Luxations, edited by Bichat, 
nor elsewhere. Bichat even says positively that " Desault himself did 
not always prevent the shortening of the limb." 2 He declares, however, 
that " Desault has cured, at the Hotel Dieu, a vast number of fractures 
of the os femoris, without the least deformity." 3 

Dr. Dorsey, of Philadelphia, who employed the apparatus of Desault, 
as modified by Physick and Hutchinson (Fig. 147), was equally suc- 
cessful. 4 

Attention has already been called, in the chapter on General Prog- 
nosis, to the published statements of Dr. Sayre relating to this subject ; 

Fig. 147. 



la 



Physick' s splint. — The splint is intended to reach to the axilla, but the counter-extension is made by 
a perineal band. Physick employed a second, long, inside splint. 

but it will be necessary to note again in this place, that he asserts that 
all fractures of the femur may be made to unite without shortening ; and 
to add that, in proof of the latter assertion, Dr. Sayre, at the meeting of 
the American Medical Association in Detroit, Michigan, in 1874, declared, 
when the accuracy of his measurements were called in question by some 
of the gentlemen present, that " he knew his measurements were correct, 
that Dr. Frank Hamilton had made the measurements, and that he was 
a man who was so violently opposed to the theory that, in his published 
writings, he had denied the possibility of any oblique fracture being cured 
without shortening. For this reason he (Dr. S.) had asked him to meas- 
ure the patients. He said if seven successive cases would be presented, 
he would agree to give up his opposition to the theory. He found the 
cases and surrendered." 5 

I was not present when these statements were made, but in the follow- 
ing number of the same journal in which they first appeared I called 
attention to their untruthfulness. And I will now repeat, that I have 
never said in any of my published writings or elsewhere, that it was im- 
possible that any oblique fracture of the femur could be cured without 
shortening, and I never entertained such an opinion ; but, while I have 

1 Op. cit., p. 167. 

2 A Treatise on Fractures and Luxations, etc., by P. J. Desault, edited by Xav. 
Bichat. Amer. ed., p. 251. 1805. 

3 Op. cit., p. 223. 

4 Elements of Surgery, by John Syng Dorsey, vol. i. p. 163. Phil adelpliia, 1813. 

5 Sayre, Detroit Review of Med., July, 1874. 



438 FRACTURES OF THE FEMUR. 

myself published several cases in which oblique fractures of the femur 
treated by me have united without shortening, I have declared this to 
be the exception, and not the rule. Further, I am obliged to say that 
no such conversation as that related by him ever occurred between us, 
and that I never measured or saw the cases mentioned by him. It is 
difficult for me to conceive, therefore, how this gentleman has fallen into 
these errors ; and I confess I would have been very much gratified if, his 
attention having been repeatedly and publicly through the medical jour- 
nals called to the matter, he had made some such public explanation or 
denial as would have rendered it unnecessary for me to allude to it in this 
place. 1 

Dr. Scott, of Montreal, Professor of Clinical Surgery in the McGill 
College and Physician to the Montreal General Hospital, has reported 
19 cases of fractures of the long bones, taken promiscuously and without 
selection, from his hospital service, of which 3 belonged to the clavicle, 
7 to the femur, 8 to the tibia and fibula, and 1 to the condyles of the 
humerus. All of which recovered without any degree of shortening or 
deformity ; except the case of fracture of the condyles of the humerus, 
which resulted in death. 2 

It is never a pleasant duty to call in question the accuracy of another's 
statements as to what he has himself alone seen and experienced. The 
circumstances which would justify such an expression of skepticism, 
where the witnesses, as in this case, are presumed to be intelligent and 
honest men, must be extraordinary. Such, however, I conceive to be 
the circumstances in this instance. It is certainly very extraordinary 
that a few gentlemen, whose means and appliances are concealed from 
no one, are able to do what nearly the whole world besides, with the 
same means, acknowledges itself unable to accomplish. Such is the 
fact, nevertheless ; and our lack of faith in their testimony is only a 
necessary result of our experience, and of the experience of the vast 
majority of practical surgeons, as opposed to them. 

I might properly enough dismiss this subject with no farther argument 
than may be found in the overwhelming testimony of practical surgeons, 
that broken femurs do in their experience rarely unite without more or 
less shortening; but I cannot avoid calling attention to the evidence of 
the falsity of the opposite opinion, which is furnished by the testimony 
of the very persons who themselves claim to have obtained such fortunate 
results. 

It is not, as might have been supposed, one particular form of dress- 
ing, which, in itself peculiar, and more perfect than all others, has fur- 
nished these results. On the contrary, the plans of treatment have been 
constantly unlike, and sometimes quite opposite. Thus, Desault used a 
straight splint, with extension and counter-extension, and he refused to 
adopt the flexed position recommended by Pott, because his experience, 
and the experience of other French surgeons, had taught him its in- 
utility. 3 Adopting the straight position, he made perfect limbs ; with the 
flexed position he found it impossible to do so. 

' Hospital Gaz. and Archives of Clinical Surgery, April 11, 1878. Editorial. 

2 "Medical Chronicle," of Montreal, vol. i. No. 7, 1853. 

3 Works of Desault, op. cit., p. 225. 



FRACTURES OF THE SHAFT OF THE FEMUR. 



439 



Dorsey used the splint of Desault, as modified by Physick and Hutch- 
inson. Sayre, who formerly used the double- or triple-inclined plane, 
or flexed position, has of late adopted the straight position, with plaster of 
Paris, and with both alike claims to have made only perfect limbs. 

South, whose success seems to have been equal to that of Desault or 
Dorsey, adopts also the straight position ; but he makes no permanent 
extension, except what may be accomplished through the medium of four 
long side splints applied after " gentle" extension has been made by the 
assistants. 

Mr. Amesbury, on the other hand, made perfect limbs only with his 
own double-inclined plane ; and speaking in general of the various plans 
hitherto contrived, not excepting that invented by Desault, or the method 
practised by South, which had already been recommended by several 
surgeons, he declares that " they are seldom able to prevent the riding 
of the bone, and preserve the natural figure of the limb. Indeed, so 
commonly does retraction of the limb occur under the use of the differ- 
ent contrivances usually employed, that I have heard a celebrated lec- 
turer (now retired) in this town publicly assert that he never saw a frac- 
tured thigh-bone that had united without riding of the fractured ends I" 1 
And in his General Inferences he uses the following emphatic language : 
" The contrivances which are commonly used in the treatment of these 
fractures do not sufficiently resist the operation of the forces above- 
mentioned, but suffer their influence to be exerted upon the bone, in all 
cases more or less injuriously, and at the same time often assist in pro- 
ducing displacement of the fractured ends ; so that deformity, differing 
in kind and degree in different cases, is almost the constant result of 
fractures of the femur treated by these means." 2 

On the other hand, Mr. Gamgee broadly contradicts the statements of 
Desault, South, Dorsey, and Amesbury, and does not hesitate to admin- 
ister a severe rebuke even upon the illustrious Liston : " Pott's plan, the 

Fig. 148. 




Liston's method, recommended by Samuel Cooper, Fergusson, Pirrie, and others 



long splint, Mclntyre, and their modifications, as a rule entail sensible 
deformity, which in many cases is very considerable. It is a significant 
fact that though the example established in University College Hospital 
by the late Mr. Liston, of treating fractures of the thigh by the long 
splint, and of the leg by the modified Mclntyre (a double-inclined plane), 
which are admitted equal, if not superior, to other splints, was rigidly 



Amesbury on Fractures, etc., vol. 



i. p. 



310. 



2 Op. cit., vol. i. p. 364. 



440 FRACTURES OF THE FEMUR. 

followed in that institution, the patients admitted with broken thighs or 
legs were frequently discharged with manifest deformity." 1 

With how much force Mr. Gamgee's own remarks as to the experience 
of the University College Hospital will apply to the starched bandages 
used by himself, the reader will be able to determine when referred to 
the opinion of Velpeau, already quoted, who claims no result better than 
an average shortening of half an inch. M. Velpeau prefers and advo- 
cates the starched bandages, but he does not claim to be able to prevent 
a shortening of the bone. 

" What other modes of treatment would have given such results ?" 
This question, propounded, no doubt honestly, by Mr. Gamgee, has here 
its fair and satisfactory answer. Almost any of the various modes 
named ; for if we must receive his testimony, we are equally bound to 
receive the testimony of Desault, South, Dorsey, Amesbury, Scott, and 
Say re. If we give credit to Mr. Gamgee, so far as to doubt the state- 
ments of these latter as to the degree of success claimed by them, by the 
same rule we must doubt his own statements also as to the degree of success 
claimed by himself. This I say with all sincerity and kindness, fully 
believing that these gentlemen are mistaken, and not that they intention- 
ally misrepresent the facts. 

By a reference to my Report on Deformities after Fractures, it will 
be seen that the average shortening in fractures of the upper third of 
the femur, in the cases examined by me, was about four-fifths of an inch ; 
in the lower third it was a fraction over three-quarters, and in the middle 
third a fraction less than three-quarters of an inch ; and the average of 
the whole number was almost exactly three-quarters of an inch (three- 
quarters and one-forty-seventh). These analyses were made upon simple 
fractures, and were exclusive of those in which no shortening at all oc- 
curred. An analysis which included also those which had not shortened, 
reduced the average shortening to half an inch and about one-tenth. 

An examination of cabinet specimens does not present a result so 
favorable even as this. Of nineteen fractures of the shaft of the femur 
contained in Dr. Mutter's cabinet, not one seems to have been shortened 
less than one inch. Specimen B 63, fracture of the middle third, is 
united with a shortening of two inches and a quarter ; and specimen B 
130, imperfectly united after a fracture through the middle third, is over- 
lapped three and a half or four inches. 

In conclusion, I wish to say briefly that, in view of all the testimony 
which is now before me, I am convinced — 

First. That in the case of an oblique fracture of the shaft of the 
femur occurring in an adult, whose muscles are not paralyzed, but which 
offer the ordinary resistance to extension and counter-extension, and 
where the ends of the broken bone have once been completely displaced, 
no means have yet been devised by which an overlapping and conse- 
quent shortening of the bone can generally be prevented. 2 

1 Advantages of the Starched Apparatus, by Joseph Sampson Gramgee. London, 
1853, pp. 54, 55. 

2 In the three first editions of this treatise the word " generally" is omitted ; hut a 
later experience, with improved appliances, has supplied to me, both in my own 
practice and in the practice of others, a few examples of perfect union under the con- 



FRACTURES OF THE SHAFT OF THE FEMUR. 44.1 

Second. That in a similar fracture occurring in children or in persons 
under fifteen or eighteen years of age, the bone may quite often be made 
to unite with so little shortening that it cannot be detected by measure- 
ment ; but it must not be forgotten that with children especially it is 
exceedingly difficult to measure very accurately. 

Third. That in transverse fractures, or oblique and denticulated, 
occurring in adults, and in which the broken fragments have become 
completely displaced, it will generally be found equally difficult to pre- 
vent shortening ; because it will be found generally impossible to bring 
the broken ends again into such apposition as that they will rest upon 
and support each other. 

Fourth. That in all fractures, whether occurring in adults or in 
children, w T here the fragments have never been completely or at all 
displaced, constituting only a very small proportion of the whole number 
of these fractures, a union without shortening may always be expected. 

Fifth. That when, in consequence of displacement, an overlapping 
occurs, the average shortening of simple fractures in adults, where the 
best appliances and the utmost skill have been employed, is from one-half 
to three-quarters of an inch. 

If we consider the muscles alone as the cause of the displacement in 
the direction of the long axis of the shaft, the shortening of the limb, 
other things being equal, must be proportioned to the number and power 
of the muscles which draw upwards the lower fragment. This will vary 
in different portions of the limb, but nowhere will this cause cease to 
operate, nor will its variations essentially change the prognosis. 

I have not intended to say that other causes do not operate occasion- 
ally in the production of shortening, but only that muscular contraction 
is the cause by which this result is chiefly determined, and that its 
power will be ordinarily the measure of the shortening. 

Conditions of a Faithful Measurement of the Thigh. — The fact that 
a patient walks without any halt, is no evidence that the limb is not 
shortened. In this regard patients are very unlike ; one having a short- 
ening of only half or three-quarters of an inch may limp perceptibly, 
while another with a shortening of an inch, or even an inch and a half, 
may not limp at all. This has been frequently observed ; and it will be 
easily understood if, standing erect with the right foot on a block one 
and a half inches in height, the left foot is planted upon the floor. It 
will then be seen that the left foot can be brought to the floor without 
disturbing the erect position of the body. Nor is it any more a proof 
that the limb is not shortened because, while in the recumbent posture, 
the heel can be brought down to the level of the other. 

Measurements made from the umbilicus, or from the symphysis pubis, 
are always indefinite and unreliable. Velpeau's idea of measuring from 
the folds of the belly, immediately above the ilium, is unsound. Mr. 

ditions named. The word "generally" was therefore added in the fourth edition, 
and is retained in this. Exactly what percentage of perfect cures may reasonably he 
expected cannot at present he determined, hut it is certainly very small. It has 
never been my opinion that a shortening must inevitably result as a consequence of 
the absorption of the ends of the bone. When shortening occurs I think it is always, 
or almost always, the result of overlapping of the fragments. 
29 



442 FRACTURES OF THE FEMUR. 

Bryant's suggestion that we measure from the trochanter major, by what 
he terms the ilio-femoral triangle, in order to determine the question of 
a fracture of the neck, is liable to the very serious objection that the 
exact position of the top of the trochanter cannot, in most cases, be 
clearly determined. 

The method most generally practised, is to measure from the round 
end of the anterior superior spinous process of the ilium to the internal 
or external malleolus ; but even this is not very trustworthy. It is 
exceedingly difficult to fix accurately upon the same point upon the two 
sides, and an error of half an inch is very common when this method is 
adopted. 

The patient should repose upon his back, upon an even surface, with 
the lower extremities as nearly as possible in the line with the axis of 
the body, the two wings of the pelvis being in the same (horizontal) 
line. A flexible, but firm, graduated tape is to be preferred to the steel 
tape measure. The foot being steadied by an assistant, the surgeon 
should put his thumb-nail against the line where it joins the ring, and 
push his nail into the skin just beloiv the anterior superior spinous pro- 
cess of the ilium, pressing firmly up and back, the flat surface of the 
nail resting upon the skin. In this way he will obtain a fixed point, and 
he can obtain an exactly corresponding point upon the opposite side. 
Below, the measurement may be made from either malleolus, but the 
outer has the most defined extremity, and is generally to be preferred. 
In most cases, for some months after the termination of the treatment, 
there is some swelling about the ankle, which renders it necessary to use 
great care in defining the point of the malleolus. The thumb-nail of the 
opposite hand may be used for this purpose, resting vertically upon the 
skin (flat against the lower end of the malleolus). The same method 
may be employed in measuring a leg, as in measuring a thigh. 

Dr. B. F. Gibbs, of the U. S. Navy, and Dr. S. B. Collins, of Phil- 
adelphia, have recently suggested and employed mechanical apparatus, 
of ingenious construction, for the purpose of rendering these measure- 
ments more accurate ; l but neither of them are sufficiently simple to be 
brought into general use, except in hospitals and dispensaries. 

Allusion has already been made in the chapter on General Prognosis 
to the fact that the bones of the lower extremities as well as other long 
bones are not always, nor perhaps generally, in the normal condition, of 
exactly equal lengths. Dr. A. Garson, of London, in the examination 
of seventy skeletons, ranging from twelve years upwards, found only ten 
per cent, which were of exactly equal length. 2 Corydon La Ford, Pro- 
fessor of Anatomy at Ann Arbor, however, in the measurement of 
skeletons, found the inequality of the length of the lower limbs excep- 
tional rather than as constituting the rule. Garson and Wight agree that 
the left leg was most often the longest. In most cases these differences 
are slight, but occasionally they are considerable. As to the practical 
deductions to be made from this fact of asymmetry, it has been suffi- 
ciently considered in the chapter on General Prognosis. 

1 Gibbs, Collins, Amer. Journ. Med. Sci., Jan. 1877, pp. 139, 144. 

2 Garson, Amer. Journ. Med. Sci., Oct. 1879, from Journ. Anat. and Phys., July, 
18*79. 



FRACTURES OF THE SHAFT OF THE FEMUR 



443 



Treatment. — All the early surgeons, so far as we know, adopted the 
straight position in the treatment of fracture of this bone, either with 
simple lateral splints, or with long splints, with or without extension, or 
with only rollers and compresses, or with extension alone. 

Such was the unanimous opinion and practice of surgeons until about 
the middle of the last century, at which time Percival Pott wrote his 
remarkable treatise on. fractures, a work distinguished for the originality 
and boldness of its sentiments, and which was destined soon to revolution- 
ize, especially throughout Great Britain, the old notions as to the treat- 
ment of fractures, and to establish in their stead, at least for a time, 
what has been called, not inappropriately, the " physiological doctrine," 
the peculiarity of which doctrine consisted in its assumption that the 
resistance of those muscles which tend to produce shortening can gene- 
rally be sufficiently overcome by posture, without the aid of extension ; 
and that for this purpose, for example, in the case of a broken femur, it 
was only necessary to flex the leg upon the thigh, and the thigh upon 
the body, laying the limb afterwards quietly on its outside upon the bed. 

Fig. 149. 




Double-inclined plane formerly employed in Middlesex Hospital, London. 



Very few surgeons, even of his own day, ever gave in their full adhe- 
sion to the exclusive physiological system as taught and practised by Pott 
himself, but multitudes, especially among the English, adopted in gene- 
ral his views, only choosing to place the patients upon their backs rather 
than upon their sides, and laying the limbs flexed over a double-inclined 
plane. To the support of this system of Pott's, thus modified, Sir Astley 
Cooper, C. Bell, John Bell, Earle, White, Sharp, and Amesbury lent 
the influence of their great names, and its triumphs, so far as the judg- 
ment of British surgeons was concerned, soon became complete. 

In France, and upon the continent generally, the reception of this sys- 
tem was more slow and reluctant ; but Dupuytren, now for once taking 
ground with his great rival, Sir Astley Cooper, adopted almost without 
qualification these novel views. The decision of Dupuytren determined 
the opinions of a large portion of the continental surgeons ; and had it 
not been for the early and decisive opposition of Desault and Boyer, the 
great surgeon of St. Bartholomew might have continued for a long time 
to have enjoyed a triumph upon the continent, and perhaps throughout 
the world, equal to that which had already been decreed to him in Great 
Britain. 

On this side of the Atlantic, the practice of Pott, at least in so far as 
it applied to the treatment of fractures of the thigh, never gained a dis- 



444 



FRACTURES OF THE FEMUR. 



tinguished advocate ; and but few ever adopted the practice as modified 
by White, Amesbury, Bell, A. Cooper, etc. 



Fig. 150. 




Amesbury's splint. 

But whatever may have been the early success of these doctrines, 
either here or elsewhere, it is certain that a strong reaction has taken 
place, and that gradually, in all parts of the world, the opinions of prac- 
tical surgeons have been settling back into their old channel. It would 

Fig. 151. 




Amesbury's splint applied. 



be difficult to find to-day, in France or Germany, a dozen distinguished 
surgeons who adopt universally the flexed position in the treatment of 
fractures of the femur ; and in England the reaction is, if possible, even 
more complete. 



Fig. 152. 




Boyer's splint. 



In my tour of 1844, during which I visited very many of the hospitals 
of Great Britain, and upon the continent of Europe, and in my later tour 
of 1872, I do not remember to have seen the flexed position once em- 
ployed in the treatment of a broken thigh ; and I shall presently show 
that the straight position is at the present moment very generally adopted 
by the best American surgeons. 

There have been, then, three grand epochs in the history of the treat- 
ment of fractures of the thisi;h. 



FRACTURES OF THE SHAFT OF THE FEMUR 



445 



First. That in which the straight position was universally adopted, 
and which reaches from the earliest periods to the period of the 
writings of Pott, or to about the middle of the last century. 

Second. The epoch of the flexed position, which, inaugurated by 
Pott, had already begun to decline at the beginning of the present cen- 
tury, and which may be said to have been completed within less than 
one hundred years from the date of its first announcement. 

Third. The epoch of the renaissance, or that in which surgeons, by 
the vote of an overwhelming majority, have declared again in favor of 
the straight position. This is the epoch of our own day. 

Although American surgeons have generally adopted the straight 
position in the treatment of fractures of the thigh, yet the form and 
construction of the splints employed have been greatly varied. The 
simple long splint of Desault, and the more complicated apparatus of 
Boyer (Fig. 152) have each their advocates; but it is seldom that we 
meet with these, or with any of the other forms of apparatus originally 
employed in foreign countries, without noticing that they have been 
subjected to considerable modifications ; indeed, most of the straight 
splints as well as double-inclined planes in use at present among Ameri- 
can surgeons may fairly be regarded as original inventions. 

Nathan Smith, of New Haven ; J Nathan R. Smith, of Baltimore ; 2 
Dr. James McNaughton, of Albany; 3 J. T. Hodgen, of St. Louis ; and 
Nott, of Mobile, are the only American surgeons of distinguished repu- 
tation, and with whose practice I am familiar, who have recommended 
exclusively the double-inclined plane. 

Fig. 153. 




Nathan E. Smith's suspending apparatus, or double-inclined plane. 



Dr. Nathan R. Smith has introduced a modification of the double- 
inclined plane in what is known as his " anterior splint," and which is 
intended also as a suspending apparatus. I saw it employed a good 



deal in the treatment of gunshot fractures ot the thigh 



and leg in our 



1 Amer. Med. Rev., published at Philadelphia, 1825, vol. ii. p. 355 ; also Medical 
and Surgical Memoirs of Nathan Smith, published at Baltimore, pp. 129-141. 

2 Med. and Surg. Memoirs, pp. 143-162. See also Geddings, Baltimore Med. and 
Surg;. Journ., vol. i., 1833; and Sargent's Minor Surgery, p. 171. 

3 Trans. Amer. Med. Assoc, vol. x. p. 317. Rep. on Defor. after Frac. 



446 



FRACTURES OF THE FEMUR 
Fig. 154. 




Josiah C. Nott's double-inclined plane. 
In this apparatus the limb is secured to the splint by vertical pins and leather straps ; the upper 
surface of the thigh splint is carved out a little, to fit the thigh ; the two portions are articulated by 
a joint like that of a carpenter's rule, and this joint may be steadied by a horizontal bar underneath. 
For the rest, the drawing sufficiently explains itself. 

various military hospitals during the progress of the civil war, especially 
at the South. It is my opinion, however, that it is more applicable to 
gunshot fractures of the leg than to those of the thigh. 

Fig. 155. 




plint. 



The splint, if splint it can be properly called, is simply a frame com- 
posed of stout wire and covered with cloth, which being suspended above 



Fig. 156. 




N. K. Smith's anterior splint, applied for a fracture of the thigh. 

the limb, allows the limb to be suspended in turn to it by rollers ; the 
rollers passing around both limb and splint from the foot to the groin. 



FRACTURES OF THE SHAFT OF THE FEMUR. 



447 



Wire of the size of No. 10 bougie is usually employed. The length of 
the splint should be sufficient to extend from above the anterior superior 
spinous process of the ilium to a point beyond the toes, the lateral bars 
being separated about three inches at the top and one-quarter of an inch 
less at the lower extremity. 

In the case of a broken thigh, the upper hook, to which the cord for 
suspension is to be fastened, ought to be nearly over the seat of fracture, 
and the lower hook should be placed a little above the middle of the leg. 

The modification of Smith's anterior splint, suggested by Dr. James 
Palmer, United States Navy, will be sufficiently explained by the accom- 
panying woodcut, 1 Fig. 157. 

Fig. 157. 




Palmer's modification of the anterior splint 



Dr. G. E. Porter, of Lonaconing, Maryland, who prefers N. R. 
Smith's apparatus, elevates the foot of the bed to insure counter-exten- 
sion with the weight of the body, but in doing this he practically yields 
the point of allowing the patient to rise and sit in bed. He employs, 
also, strips of " stout, unstretching brown drilling," instead of the con- 
tinuous roller. 2 



1 Amer. Journ. Med. Sci., 1865 ; also, Mechanical Therapeutics, etc., by Philip S. 
Wales, M.D., U. S.N., 1867. 

2 Porter, Med. & Surg. Reporter, March 18, 1876. 



448 



FRACTURES OF THE FEMUR. 



Dr. J. S. Hodgen, of St. Louis, Mo., has for many years employed a 
wire suspension splint, which I much prefer to Smith's. The bars of 
wire are traversed with a cotton sacking, upon which the limb is laid. 1 
I regret that in previous editions, when referring to this apparatus, I 
have spoken of it as having been employed by Dr. Hodgen in gunshot 
fractures alone, while in fact it is employed by him in all, or nearly all 
fractures of the femur. The error comes, probably, from the circum- 
stance that I had myself seen it used only for gunshot fractures. 

Fig. 158. 




Hodgen's suspension apparatus. 

On the other hand, among the advocates of the straight position are 
found the names of Physick, Dorsey, Gibson, Horner, J. Hartshorne, 
H. H. Smith, Neill, R. Coates, H. Hartshorne, Norris, Gross, Ashhurst, 
Agnew, and Packard, of Philadelphia ; Buck, Markoe, Stein, Post, 
Howe, Ward, Weir, Mason, Sands, and Little, of New York, and many 
others. In this city I know of no surgeon who employs habitually the 
flexed position. 

Says Dr. Gross : " Many years ago, before I had much experience in 
this class of injuries, I occasionally employed the flexed position, but I 
soon found that it was objectionable, on account of the great difficulty in 
maintaining an accurate apposition to the ends of the fragments. Of late 
years I have confined myself entirely to the use of the straight position, 
and I have never had any cause to regret it. In the adult, I sometimes 
employ the apparatus of Desault, as modified by Physick, but much 
more frequently one of my own construction, somewhat upon the princi- 
ple of that of Dr. Neill, described in the Philadelphia Medical Exami- 
ner fov 1855. I have used it for nearly twenty years, and it has gen- 
erally answered the purpose most admirably in my hands. It consists 
simply of a box for the thigh and leg, with a foot and two crutches, one 
for the axilla and the other for the perineum, to make the requisite ex- 



Hodgen, Treatise on Mil. Surg., by F. H. Hamilton, 1865, p. 411. 



FRACTURES OF THE SHAFT OF THE FEMUR. 



449 



tension and counter-extension. With such an apparatus, an oblique 
fracture of the thigh can be treated with great comfort to the patient, 
and with the assurances of a good limb. In children, I have effected 
some excellent cures simply by means of a sole-leather trough, well 
padded, and provided with a footpiece. 

" The great objection to the flexed position is the difficulty of keeping 
the ends of the broken bones in apposition ; the upper one having a con- 
stant tendency to pass away from the inferior. Other objections might 

Fig. 159. 




John Weill's straight thigh splint. — Extension and counter-extension made at the same time. 

be urged against the flexed position, but this is quite sufficient to induce 
me to reject it." 1 

The following wood-cuts, from Fig. 160 to 168 inclusive, illustrate the 
apparatus formerly used in the Massachusetts General Hospital, Boston. 
(From drawings furnished by Dr. L. M. Sargent.) 



Fig. 160. 



Fig. 161. 





Pelvic belt and perineal strap. 



Footpiece and screw. 



Fig. 162. 




Lateral view of the apparatus, without the belt. 



1 Trans. Am. Med. Assoc, vol. x. ; also, System of Surg., by S. D. Gross, 1859, p. 
221. 



450 



FKACTUKES OF THE FEMUR. 



" The belt is made of strong webbing, having pockets on each side, 
to receive the long splint. It is also furnished with straps and buckles. 



Fig. 163. 




Front view of the apparatus, with folded sheet laid across. 
Fig. 164. 




Apparatus applied. 
Fig. 165. 




Side view of apparatus applied. 
Fig. 166. 




Fig. 167. 




Figs. 166, 167. Mode of making extension with adhesive plaster. 

The perineal strap (Fig. 168), corresponding to the injured side, is kept 
constantly buckled, while the other may be occasionally loosened, or left 
off, as its purpose is only to steady the apparatus. Where the straps 
pass under the perineum, they are covered with wash-leather. Before 
applying the belt, a pillow-case or two may be passed around the waist. 
The padlock is only to be used in case the patient persists in unbuckling 
the straps. The splints, being applied (with also short side-splints, junks', 



FRACTURES OF THE SHAFT OF THE FEMUR 



451 



containing bran or sand, etc.), are to be secured more firmly to the limb 
by bands of webbing and buckles." 

Dr. Bigelow informs me that Flagg's apparatus is not now in use at 
this excellent hospital, and has not been for some time ; but I have re- 
tained the illustrations because they exhibit much ingenuity, and serve 
to explain the gradual progress of improvement in the treatment of these 
fractures. 

At present, the surgeons of the Massachusetts General Hospital em- 
ploy essentially the same apparatus which I at present employ and shall 
hereafter describe ; extension being made by a weight and pulley, with 
the aid of adhesive straps, and counter-extension being effected by the 
weight of the body, by elevating the foot of the bed. After which, 
coaptation splints and junks are applied in the usual manner. Ether is 
employed in all cases before making extension, the apparatus being ap- 
plied at the earliest possible moment. 

The late Dr„ Neill, of Philadelphia, contrived a very ingenious mode 
of both extension and counter-extension at the same moment, by means 
of a twisted rope, which is fastened by its two ends respectively to the 
perineal band above and the extending band below. (For illustrations 
of this apparatus see five first editions of this book.) 

The two Warrens, father and son, of Boston ; Kimball, of Lowell ; 
Sanborn, of Lowell, Mass. ; Mussey, of Cincinnati, Ohio ; J. B. Flint, 
of Louisville, Ky. ; Armsby, of Albany; 1 Moore, of Rochester; and 
Potter, of Batavia, have also recommended some form of the straight 
splint. Said the late Dr. Mussey : — 

" For all fractures of the thigh-bone I employ the extended position 
of the limb. There are but few cases in which extending force is not 
necessary to prevent the degree of deformity or 
shortening which would occur without it. Of 
thirty specimens of fracture of the shaft, in my 
collection, only two are transverse. In frac- 
tures of the neck, especially with old subjects, 
I sometimes avoid the application of any kind 
of apparatus for permanent extension; but in 
all cases, whether of the neck or shaft, where 
such extension is attempted, I have found the 
straight position of the limb to be the most re- 
liable." 

Daniell, of Savannah, Georgia, recommends 
the straight position, the limb being laid in a 
kind of long box, and the extension being made 
with a weight and pulley. 2 Dugas, of Augusta, 
Georgia, employs the pulley and weight also, but uses the long side- 
splint instead of the box. 3 Howe, of Boston, recommended a similar 
method in 1824. 4 

Dr. Gurdon Buck, of New York, used the pulley, without the long side- 



Fig. 168. 




Perineal band secured with a 
padlock. (Flagg's apparatus.) 



1 Trans. Am. Med. Assoc, vol. x. Report on Deformities after Fractures. 

2 Amer. Journ. Med. Sciences, vol. iv. p. 330, 1829. 

3 Southern Med. and Surg. Journ., Feb. 1854. 

4 Howe, New Eug. Med. Journ., July, 1824. 



452 



FRACTURES OF THE FEMUR. 



splint. His perineal band was composed of india-rubber tubing, " of one 
inch calibre, two feet in length," stuffed with bran or cotton lampwick, 
and covered with canton flannel, which covering may be renewed as often 
as may be necessary ; the extending bands or adhesive plasters termi- 
nating below the foot in an elastic rubber cord. (Fig. 169.) 



Fig. 169. 




Gurdon Buck's apparatus, with, perineal band of india-rubber tubing, and an elastic cord for 
suspending the weight. 

William E. Horner, of Philadelphia (Fig. 170), employed a long outside 
splint extending into the axilla, and padded, so as to avoid the necessity 
of junks ; with fenestra,.for extending and counter-extending bands ; and 
also a foot-piece ; and a short inside splint, made to extend from the peri- 
neum to the bottom of the foot. Across the excavated upper end of this 

Fig. 170. 




W. E. Horner's thigh-splint. 



splint, a strip of leather is stretched to receive the pressure of the peri- 
neum, while the perineal band is made to pass through two firm leather 
loops on the outside of the splint. 1 



Fig. 171. 




Joseph E. Hartshome's thigh-splint. 



Dr. Joseph E. Hartshorne, of Philadelphia (Fig. 171), rejected the 
perineal band altogether, and sought to make the counter-extension by 

1 Treatise on the Practice of Surgery, by Henry H. Smith. 



FRACTURES OF THE SHAFT OF THE FEMUR. 



45^ 



means of the internal long splint alone ; and for this purpose he cushioned 
the head of the inside splint, as will be seen in the accompanying drawing. 
The head of the outside splint may also be cushioned, but not for the pur- 
pose of employing it as a means of counter-extension. The outside splint 
is so adjusted to the foot-piece, that it may be removed in case of a com- 
pound fracture, without disturbing either the extension or counter-exten- 
sion. 1 

Dr. David Gilbert, of Philadelphia (Figs. 172, 173), has published an 
account of a method of making counter-extension with adhesive strips, 

Fig. 172. 




D. Gilbert's mode of making counter-extension and extension. 

1. Anterior and posterior counter-extending adhesive bands, two and a half inches wide, crossing 
each other before they pass through the mortise holes. 2. The same, crossing at the upper part of 
thigh and perineum. 3. Horizontal pelvic band, which may be three inches wide. 4. Extending 
bands, receiving strap of tourniquet in the hollow of the foot. 5. Tourniquet. 

which he had employed not only in fractures of the thigh, but also of 
the leg, extension being made with the tourniquet of Petit. A broad 



Fig. 173. 




Gilbert's apparatus applied in a case of fracture of both thighs. 

piece of plaster also is made to encircle the pelvis, in order to bind 
down the counter-extending bands more firmly to the body. Additional 
strips are employed when they seem to be required. 2 

H. L. Hodge, also of Philadelphia, adopting the same means of 
counter-extension, namely, adhesive plaster bands, has modified the idea 



1 Treatise on the Practice of Surgery, by Henry H. Smith. 

2 Gilbert, Amer. Journ. Med. Sci., April, 1859, pp. 410-424. 



454 



FRACTUEES OF THE FEMUE 



of Gilbert by securing the strips of plaster to the sides of the body in- 
stead of the perineum, and attaching them to an iron rod which is made 
to project from the top of the splint beyond the shoulder. 1 (Fig. 174.) 



Fig. 174. 




#1111 w r^> vf 

H. L. Hodge's method of counter-extension in fracture of the femur. 

Lente, of New York, many years ago, before the value of elevating 
the foot of the bed, and depending upon the weight of the body to make 
counter-extension, was understood, constructed an apparatus by which 
he hoped, in some measure, to obviate the inconveniences of the perineal 
band, by distributing the pressure between the tuberosity of the ischium 
and the groin. He, therefore, supplied his splint with an iron brace, 
extending in a curved line from the upper part of the external splint, 
directly across the body, to the median line, and cushioned on its inner 
surface. To this is attached the anterior extremity of the perineal 
band. By this arrangement the pressure is not only in a great measure 
removed from the groin, and from the vessels, etc., on the inside of the 
thigh, but also the direction of the counter-extension is in a line with the 
axis of the body. The posterior extremity of this band is secured, not 
to the upper end of the splint, as is usually done, but to the splint 
several inches lower down, where it will take a more secure hold upon 
the under surface of the tuberosity and nates. Both extremities of the 
band are elastic. Extension is made with a screw, inclosing a strong 
spiral spring in its ferrule, or with adhesive plasters, .a pulley and weight, 
at the option of the surgeon. 

The splint is made in sections, for adaptation to different persons, and 
for convenience in packing. It extends no higher than the alee of the 
pelvis, and is secured to the body at this point by a padded pelvic band. 
The accompanying illustration (Fig. 175) will sufficiently explain the 
remaining features of the apparatus. 

The apparatus invented by Dr. Burge, of Brooklyn, is both a fracture- 
bed and a splint, and was constructed with the same view of removing 
pressure from the front of the groin. The principles involved and the 
general plan of construction will be sufficiently explained by a study of 
the accompanying woodcuts. (Figs. 176, 177.) 



Hodge, Amer. Journ. Med. Sc-i., April, 1860. 



FRACTURES OF THE SHAFT OF THE FEMUR 



455 



Dr. T. W. Simmons, of Hagerstown, Maryland, who declares that he 
is unable to see how extension can be made in the flexed position, has 



Fig. 175. 




Lente's thigh splint. 



constructed a suspension apparatus for horizontal extension in fractures 
of the lower extremities. It is composed of a suspending bar, two side 
splints, and a foot piece. (Fig. 178.) 



Fig. 176. 




Burge's apparatus. 



The suspending bar is made of iron, three feet long, one and a quarter 
inches wide in its vertical diameter, and three-quarters of an inch thick. 
It is furnished with slots, and eyes for suspension. The two side pieces 
or splints are of wood, long enough to extend from the malleoli to the 



456 



FEACTURES OF THE FEMUR. 



body, the outer splints being extended above the ilium. They are sepa- 
rated from each other by two strong wires, and suspended from the sus- 



Fig. 177. 




Burge's apparatus applied. 



pension bar by leather straps, which are made fast to the bar by the aid 
of metallic ears, through which the straps pass, the metallic ears being 



Fig. 178. 




T. W. Simmons's suspension-extension apparatus. 



secured in the slots by thumb screws, thus providing for adjustment and 
fixation. 

The apparatus is now suspended from the ceiling by two ropes, carried 



FRACTURES OF THE SHAFT OF THE FEMUR. 457 

obliquely, as seen in the drawing, to the hook in the ceiling, and then 
brought down to the bed and tied. 

A bandage is then made to inclose the whole length of the splints, 
from the ankle to the groin, by continuous turns from side to side. 
Upon this the limb is laid, and then the foot is applied snugly to the 
foot-piece and made fast by long and wide adhesive strips laid the whole 
length of the leg and passed beneath the foot-piece ; this to be reinforced 
by a roller if necessary. It may also be necessary to inclose the whole 
length of the splints, including the thigh and leg, in another roller. The 
long outside splint is secured to the body by a pelvic band or roller. 

Great care should be exercised in adjusting the bearings so that the 
limb does not fall to the one side or the other, and that the foot applies 
easily and at the proper angle to the foot-board. 

The same mode of suspension and extension may be employed in using 
a box or a plaster-of-Paris splint. 1 

At the " German Hospital," in this city, under the observation of the 
late Drs. Krakowizer and of Guleke, visiting surgeons, five cases are 
reported as having been treated by Buck's extension and one by plaster 
of Paris. Buck's extension had given the best results. At the " Pres- 
byterian Hospital," also, Dr. D. M. Stimson reports that Buck's exten- 
sion is generally emplo3 7 ed. Dr. Alfred C. Post says : — 

" My ordinary practice is to treat fractures of the femur by exten- 
sion with a weight and pulley. The method seems to me as nearly 
perfect as any plan of human device can be, in promoting the comfort 
of the patient, in facilitating the urinary and fecal evacuations, and in 
securing union without deformity. In some cases union occurs abso- 
lutely without shortening, and in other cases the shortening is so slight 
as only to be detected by careful measurement. In cases carefully 
treated by this method it is rare to meet with shortening much exceed- 
ing half an inch. I have never seen a case of simple fracture of the 
femur treated in this way in which there was any such shortening or 
deformity as I have seen in some cases which have been treated by the 
use of plaster-of-Paris bandages." 

Says Dr. Weir, of St. Luke's Hospital: — 

" In hospital practice, and where in private practice I can myself 
apply plaster, I do it ; but to my students I point out that Buck's 
apparatus is a much safer method for them to use, and generally for 
practitioners whose opportunities for acquiring large experience are 
few : because I find that unless carefully applied and watched, by fre- 
quent reopening, etc., curvature and shortening will sometimes occur 
unperceived, which cannot be the case in Buck's apparatus/' 

The late Dr. Paul F. Eve, Professor of Surgery in the Nashville 
Medical College, employed the plaster of Paris, but not as an immovable 
form of dressing. Extension and counter-extension are made as in 
Buck's apparatus, and the limb is exposed to view daily and sponged. 
In order that these necessary examinations may be made, the plaster is 
applied according to the Bavarian method, so that it may be spread 
open without breaking the splint. 

1 Simmons, Am. Journ. Med. Sci., April, 1875. 
30 



458 FRACTURES OF THE FEMUR. 

The practice of treating fractures of the thigh, as well as all other 
fractures of the long bones, with the roller alone, and without either 
lateral splints or extending apparatus, first suggested by Radley, has 
found in this country but one distinguished advocate, the late Dr. Dudley, 
of Lexington, Ky. 1 Nor, with all my respect for that truly great sur- 
geon, can I persuade myself that the practice is able to accomplish in 
any degree the indications proposed, nor indeed that it is, at least in the 
hands of inexperienced surgeons, wholly safe. Dr. D., of Aberdeen, 
Miss., has reported to me one example in which, after the application of 
this bandage by a pupil of Dr. Dudley's, to a negro slave, who had a 
fracture of the femur, death of the limb ensued, and amputation became 
necessary. The negro was sixteen years old, and healthy ; the fracture 
was caused by the fall of a tree or of a branch, and was simple. The 
bandage was applied from the toes upwards to the groin, and was not 
opened for several days, at which time the whole limb was found to be 
in a state of dry gangrene, with the exception of the upper two-thirds of 
the thigh, which was swollen enormously, and partially gangrenous as 
high up as the groin. 

Dr. D. says : " Having heard the history of the case carefully stated, 
observing the leg and the lower part of the thigh to be in a state of dry 
gangrene, and seeing the marks of the bandage visibly impressed on the 
surface, my opinion was made up at the time that the gangrene had 
resulted from pressure of the bandage. The femoral artery at the groin 
was in a sound and natural state, and if I mistake not, after the limb was 
removed, it was traced to the point of obliteration where the gangrene 
commenced, and where the impression of the bandage was observed ; 
thus far, I think, it was of natural size and calibre. Hence the conclu- 
sion is inevitable, that the death of the limb resulted from the pressure 
of the bandage, and not of one of the fragments. 

" It was a curious specimen of dry mortification, and I regret that I 
did not use the means of preserving it. I was then engaged in a very 
laborious practice, thirty miles from home, on horseback, and conse- 
quently could not conveniently spare the time to attend to it as an object 
of surgical curiosity. Dr. H. and myself cut into the leg in various 
places, in order to examine the muscles, arteries, nerves, etc., but found 
the integuments so hard that it was really difficult to penetrate them 
with a knife ; the resistance to the knife was more like that of dry hick- 
ory wood than anything else." 2 

I cannot think it necessary to do more than allude to the practice of 
Jobert, of Paris, and of Swinburn, of Albany, who, rejecting side or 
coaptation splints altogether, have relied solely upon extension as a means 
of support and retention in the case of fractures of the shaft of the femur. 

The treatment of these and other fractures by plaster of Paris, paste, 
starch, or dextrin has been already considered when speaking of the 
treatment of fractures in general. Thus far my experience will not war- 
rant me in recommending the immovable apparatus, as a general plan of 
treatment in fractures of the thigh. 

1 Amer. Journ. of the Med. Sci., vol. xix. p. 270; Transylvania Journal, April, 
1836 ; Boston Med. and Surg. Journ., vol. xxxiv. p. 35. 

2 For a more complete account of this interesting case, see Buffalo Med. Journ., vol. 
xiv. p 193, Sept. 1858. 



FRACTURES OF THE SHAFT OF THE FEMUR. 459 

In the fourth edition I spoke somewhat more favorably of the results 
of this practice as declared by some of the House Surgeons of Bellevue ; 
still more lately one of the visiting surgeons has published some statis- 
tics which indicate a better average result than has been hitherto ob- 
tained by other methods ; but having since learned that these statements 
were not based altogether upon measurements made by these well-known 
and able writers themselves, I am unwilling to accept of them as trust- 
worthy testimony. 1 For a review of Dr. Van Wagenen's report of cases 
treated by the plaster of Paris in Bellevue Hospital, the reader is referred 
to the chapter on General Prognosis. 

In order to assure myself as to whether we were able to make longer 
and straighter thighs by the use of the plaster of Paris than by the 
method of extension as employed by myself and others, my later expe- 
rience has been carefully collated, but not selected ; every case in which 
the opportunity was afforded being recorded, and the results being con- 
firmed by my own testimony and the testimony of others. The facts 
thus obtained constituted the basis of an article written by me for the 
New York Medical Journal, and published in the August number for 
1874 ; but the great interest taken in the discussion of the merits of the 
Mathiesson's plaster-of-Paris dressings, both in this country and abroad, 
during the last few years, seemed to me to call for a statement of expe- 
rience which should cover a larger number of cases, although it could not 
be expected in a treatise like this to give all the cases in detail, as was 
done in the journal communication already referred to. Of the cases 
treated by plaster of Paris, and recorded in the accompanying tables, a 
majority were from the hands of other surgeons, and all AYere hospital 
cases ; in almost every instance the surgeon treating the case having had 
a large experience in the use of plaster. With very few exceptions the 
plaster was applied while the patient was under the influence of ether. 
After the plaster was applied most of the patients walked about with 
crutches ; but there were pretty frequent examples in which, for one reason 
or another, this was found impracticable, and the patients remained in bed. 

The amount of shortening has six times exceeded one inch. A con- 
siderable bend at the seat of fracture has occurred six times ; anchylosis 
of the knee, requiring surgical interference, has occurred six times, and 
in almost all cases it has been more troublesome than it is usually found to 
be after other plans of treatment ; once gangrene, amputation and death 
followed, and once abscesses of the leg, paralysis, etc. etc. 

The cases reported as treated without plaster were all treated by my- 
self. The method adopted being in the case of adults essentially that 
which is known as Buck's extension, but Avhich I have, as will hereafter 
be seen, considerably modified. In the case of children, the method has 
been uniformly that which I shall hereafter describe in its proper place 
as the method preferred by me in these cases ; permanent extension, such 
as is used in Buck's apparatus, being very seldom employed. Not one 

1 Prof. H. B. Sands, N. Y. Med. .Tourn., June, 1871 ; Dr. J. D. Bryant, N. Y. Med. 
Record, Sept. 15, 1871; Dr. S. H. St. Johns, Amer. Journ. Med. Sci., July, 1872. 
Reply to Dr. St. Johns, by the author, Hosp. Gaz., etc., May 30, 1878 ; Dr. St. Johns's 
reply, Louisville Med. News, Sept. 28, 1878 ; Lecture on Fractures of the Femur in the 
Adult, Bellevue Hosp., by the author, Med. Record, Dec. 1, 1877 ; Dr. St. Johns, on 
the same, before Academy of Med., N. Y., May 14, 1878, Med. Record, July 20, 1878. 



460 



FRACTUKES OF THE FEMUR. 



of these limbs has presented an excessive shortening — one inch being the 
maximum. Not one is bent at the point of fracture. None of the pa- 
tients had bed-sores, or troublesome anchylosis at the knee-joint. In one 
there was delayed union. Case 23 has been measured by many of the 
gentlemen connected with Bellevue, and all agree that the broken limb 
is longer than the other, yet it united promptly, and he walks without a 
halt. We have been unable, thus far, to find any other explanation of 
the increased length except the now well established fact that the normal 
lengths of thighs and of other long bones are pretty often unequal, and 
that probably this limb was originally longer than the other. The experi- 
ments of Reid 1 and of others have conclusively shown, I think, that it is 
impossible, unless at least fifty or one hundred pounds were employed in 
the extension, to stretch the muscles beyond their normal length. If a 
limb after fracture and bony union is found longer than its fellow, no 
doubt it was longer before the fracture. We cannot, therefore, appreciate 
the objection made by Dr. Sayre to permanent extension by a weight and 
pulley, that it endangers a total separation of the fragments, and conse- 
quent non-union. Five children and one adult had perfect limbs ; or, if 
we are permitted to include the case in which the limb is lengthened, two 
adults have recovered with perfect limbs. 



Cases treated with Plaster of Paris, Cont 


inuous Roller, Mathiesson 's Method. 


No. 


Age. 


Character of Point of 
fracture. fracture. 


Hospital. 


Amount of 
shorten'g. 


Deformity. 


Eemarks. 


1 

2 


Yrs. 
11 
15 


Simple. 


Middle. 
it 


Bellevue. 

St. Francis. 


Inches. 

4 
5 
8 


( Slightly 
( bent. 


( Anchylosis of 
( knee. 


3 


16 


a 


a 


Park. 


n 




( Anchylosis 


4 


17 


a 


a 


99th St. 


i 


Much bent. 


^ broken up un- 


5 


12 \ 


"With frac. 

of legs. 


Below \ 
troch. J 


Park. 


i 


a a 


( der ether. 


6 


16 


Simple. 


1 1 


Bellevue. 


3 

8 






7 


7 


" 


Middle. 


" 


1 

2 






8 


39 


" 


1 1 


" 


1 






9 


37 


a 


" 


" 


1 






10 


63 


it 


Extracap. 


< < 


1 
2 






11 


26 


it 


Middle. 


Park. 


3 






12 


24 


a 


" 


" 


H 






13 


25 


a 


a 


" 


i 






14 


30 


a 


a 


a 


ii 




Anchylosis, 


15 


21 


it 


a 


Bellevue. 


u 




it 


16 


26 


i i 


" 


i i 


4 






17 


29 


a 


" 


a 


3 

1 






18 


24 


it 


a 


a 




Delayed union. 


19 


39 


i i 


a 


99th St. 


8 
If 




20 


70 


a 


a 


Bellevue. 






No union. 


21 


44 


Compound. 


a 




2 


Bent. 




22 


66 


Simple. 


" 


a 


1 


Much bent. 


Anchylosis. 


23 


50 


" 


a 


a 


1 


Bent. 




24 


22 


a 


a 


i i 


3 




Anchylosis. 


.25 


33 


a 


Extracap. 


" 


5 

8 




26 

.2:7 


23 

27 
46 


it 

a 


( Below 
( troch. 

( Above 
{ cond. 


i i 

Park. 


Perfect. 

H 

5 
8 




f Paralysis, ab- 
( scess, etc. 


.28 




29 


5.1 


Compound. 


n 


Bellevue. 


1 
2 




( G-angrene, 
( amp., death. 


.30 


23 


Simple. 


Middle. 


99th St. 







Reid, W. W., Buf. Med. and Surg. Journ., vol. vii. p. 134, Aug. 1851. 



FRACTURES OF THE SHAFT OF THE FEMUR 



461 







Gases treated by myself, by my < 


jwn and Buck's Methods. 


No. 


Age. 


Character of 
fracture. 


Point. 


Hospital. 


Shortened. 


Deformed. 


Eemarks. 




Yrs. 








Inches. 






1 


2 


Simple. 


Middle. 


Bellevue. 


l 

4 


Straight. 




2 


6 


. It 


" 


it 


Perfect. 


" 




3 


4 


" 


;; 


Private. 


3 

j 


ti 




4 


6 


i I 




" 


Perfect. 


a 




5 


10 


I l 


<< 


Bellevue. 


ti 


a 




6 


9 


ii 


" 


" 


2 


it 




7 


15 


" 


" 


1 1 


1 
4 


t i 




8 


5 


Compound. 


" 


n 


Perfect. 


it 




9 


18 


Simple. 


it 


a 


" 


it 




10 


33 


( 4 


it 


a 


3 

8" 


11 




11 


20 


" 


it 


a 


f 


it 




12 


50 


11 


a 


a 


f 


a 




13 


35 


a 


a 


Long Is. C. 


1 


n 




14 


60 


n 


Intracap. 


Park. 


7 
8 


" 




15 


50 


a 


Extracap. 


" 


1 


it 




16 


40 


a 


a 


Bellevue. 


5 

8 


a 




17 


40 


a 


a 


" 


1 


it 




18 


35 


n 


i i 


ii 


7 
8 


a 




19 


40 


ti 


n 


ii 


1 
2" 


" 




20 


60 


a 


a 


Long Is. C. 


1 
2 


it 


Toes everted. 


21 


45 


a 


a 


Private. 


1 
2 


a 


a a 


22 


70 


a 


Neck. 


a 


1 
2" 


it 


a tt 


23 


40 


it 


Above knee. 


Bellevue. 


Lengthened. 


a 




24 


22 


" 


Middle. 


i i 




it 


Delayed union. 







It will be seen that the first table includes two cases in which serious 
results ensued. In case 30 gangrene supervened on the third day after 
the accident, and on the second, after the dressings were applied ; ampu- 
tation was made, and the patient died. In case 27 the plaster was ap- 
plied on the fifth day after the accident (November 13, 1873), and 
removed twenty days later, when the patient found he had no sensation 
in the limb below the knee ; the leg was also much swollen below the 
knee. Subsequently abscesses formed in the leg, large sloughs occurred, 
and the calcaneum became carious. 

Both of the preceding cases are reported at more length in the num- 
ber of the New York Medical Journal for August, 1871. 

These two constitute the only examples of serious accidents which 
might possibly have been due to the mode of dressing, in this table of 30 
cases, which, as has already been explained, were recorded without selec- 
tion ; but they are not all which have come under the writer's notice. 
In one case at Bellevue an enormous perineal slough was caused by the 
pressure of the plaster. In addition, also, to the case of gangrene and 
death included in the first of the preceding tables, the following have to 
be recorded: — 

Lizzie Gibbons, set. 24, fell upon the sidewalk and broke her thigh 
about six inches above the knee-joint. She was carried to Bellevue 
Hospital, and on the same day, under the influence of ether, and with 
limb extended by pulleys, plaster dressings were applied. Twenty-four 
hours later the toes looked dark, and the splint was opened about the 
foot. On the following morning the house surgeon found the limb cold, 



452 FRACTURES OF THE FEMUR. 

and sensation greatly impaired. The dressings were at once opened 
freely. Death took place on the third day. 

Charles Grim, set. 62, admitted to Bellevue Jan. 2, 1871, with a 
fracture of the cervix femoris, which had just occurred from a fall on 
the ice. On the fourth day plaster of Paris was applied with the aid of 
ether and pulleys. Two days later the record reads: " Patient has a 
large sore on sacrum, extending almost to the loins ; splint taken off ; 
extremities cold and blue ; pulse felt with difficulty ; suffering from some 
dyspnoea ; lungs emphysematous, and old fracture (?) somewhere ; this 
P. M. he died." 1 

The two following cases deserve to be mentioned in this connection, 
inasmuch as the class of casualties to which they belong are chiefly in- 
cidental to the plaster-of-Paris method. In no other form of dressing 
have anaesthetics been employed so universally. 

John Stockander was admitted to Bellevue August 2, 1872, with a 
fracture of the left femur below the trochanter. Buck's extension was 
applied at first, and on the eighteenth day the patient was placed under 
the influence of ether, the pulleys attached, and the application of the 
plaster commenced. The breathing was soon observed to be gasping. 
Ether was withheld a few minutes, when, as the breathing became 
regular, it was resumed. Soon after the pupils rapidly dilated, the 
breathing ceased, and in a few minutes more, in spite of every effort to 
resuscitate him, death supervened. There is every evidence to sustain 
the opinion that the ether was given carefully and in the usual manner. 2 

In the case of Mary Shules, No. 11 of the second table, ether was 
administered for the purpose of applying plaster ; and while extension 
with pulleys was employed, and the bandages were being applied, 
" she suddenly ceased to breathe, and her face became purple." By 
prompt resort to various expedients, including Marshal Hall's method, 
Sylvester's method, and electricity, she was rescued. " Dr. Figaro 
thinks her respiration was completely suspended two or three minutes." 3 
The attempt to apply plaster was then abandoned, and Buck's extension 
substituted, with the result of giving her a limb shortened only three- 
eighths of an inch. 

I shall hereafter mention another case of gangrene caused by the 
plaster dressing in connection with fractures of the femur in children. 

Billroth has noticed the greater frequency of non-union under the 
plaster-of-Paris treatment; and my own attention has been called re- 
peatedly to these cases. 

T. B., a laboring man, set. 60, fell Oct. 25, 1875, breaking his right 
femur near its middle. On the following day, with pulleys, the leg was 
extended until it was said to be as long as the other, and then the 
plaster-of-Paris splint applied. He left his bed, and was allowed to go 
about on crutches at the end of one week, as recommended by the 

1 A Comparison of the Results of Treatment of 308 Cases of Fracture of the Femur, 
etc., Bellevue Hospital, by Frederick E. Hyde, M.D., New York. New York Med. 
Journ., October, 1874, p. 368. 

2 Death from Ether, by W. B. Dunning, M.D., Acting House Surgeon, Bellevue 
Hospital. New York Med. Rec, October 1, 1872. 

8 New York Med. Journ., August, 1874, p. 134. 



FRACTURES OF THE SHAFT OF THE FEMUR. 463 

advocates of this method. The apparatus was removed at the end of six 
weeks, when the limb was crooked, and, as the man thought, not united. 
The surgeon did not, however, recognize the failure to unite until some 
time later. 

This man consulted me about seven months after the accident. I 
found only fibrous union of the fragments, the limb being bowed out at 
the point of fracture, and perfectly useless. 

In July, 1875, Dr. Glass, House Surgeon, called my attention to a 
similar case which had been treated in Bellevue Hospital. 

A danger in the use of plaster of Paris as a dressing for compound 
fracture of the femur has not hitherto been mentioned, namely, that in 
case of a secondary haemorrhage from the femoral artery, it would be 
impossible to compress the artery over the pubes, in Scarpa's space, or 
at any other suitable point, and the patient might die before succor 
could be given. In cases of compound fracture of the femur, from gun- 
shot injuries, such secondary haemorrhages are not very uncommon ; and 
such a haemorrhage has occurred when the femur has been broken very 
obliquely, and thrust through the flesh, and has in its course so con- 
tused the femoral artery, or has passed so near to it, as to have caused 
a subsequent sloughing of the artery. 

I do not see how one is to provide for such a possible accident ; since 
a fenestra opposite the wound would not give space sufficient to secure 
the bleeding vessel ; and a sufficient fenestra over the groin might so 
much weaken the splint as to render it of little or no value. The acci- 
dent has occurred, and may occur again ; the surgeon ought, therefore, 
in case he uses the plaster, after a compound fracture, so far as possible, 
to provide an opening sufficient for a free approach to the upper portion 
of the femoral artery, in order that pressure could be applied and the 
bleeding controlled until the vessel was secured. 

In no other limb than the thigh, is this danger so imminent, for the 
reason that no where else are the vessels which are liable to rupture so 
large. 

It has been almost the constant practice of late, in this country, to 
employ ether and the pulleys while applying the plaster, and this is 
considered one of the great essentials to success. It is proper then to 
put into the account, as against this method, the danger from anaes- 
thetics; and to inquire, perhaps, whether the usual danger attending the 
exhibition of these agents is not increased by the condition of forced 
decubitus, and of extension to which the patients are subjected while the 
plaster is being applied. 

A case reported to the South Carolina State Medical Association, in 
1874, by Dr. Robert W. Gibbes, of Columbia, S. C, furnishes the first 
opportunity yet presented to me to observe in the autopsy the result of 
treatment, in a case in which plaster of Paris has been employed accord- 
ing to the method just described. Dr. Gibbes has been kind enough to 
send me the specimen, and also photographs, from which the accompa 
nying woodcuts are made. 

Mr. J. H. W., aet. 83, weighing 165 pounds, enjoying robust health, 
fell eighteen feet, January 2, 1873, striking, as he thinks, upon the 
right hip. Dr. Gibbes was called and detected a fracture of the right 



464 



FRACTURES OF THE FEMUR. 



femur just below the trochanters. Fifteen hours after the accident, 
Dr. Gibbes, assisted by other surgeons, applied " the plaster-of-Paris 
dressing after the well-known method in vogue for several years past in 
Bellevue Hospital, my venerable patient being kept for some time sus- 
pended above the table and fully under chloroform." 



Fig. 179. 



Fig. 180. 




Dr. Gibbes's case. 

Posterior view. Anterior view. 

A, B, C, three fragments ; d, bony bridge. 

On the fourth day he made an attempt to walk, but the attempt was 
not resumed until about the eighteenth day, after which " he began to 
walk around his room daily." The apparatus was removed on the forty- 
third day. The union was firm, and the limb appeared to be shortened 
three-quarters of an inch, as determined by several careful measure- 
ments. On the 29th of June, about six months after the accident, he 
died of apoplexy. In the autopsy it was found that the femur was 
broken just below the trochanters into three fragments. 

The result of the treatment, considering his age and weight, was all 
that could have been expected ; and the preference given to the plaster, 
in this particular case, was judicious ; but the point to which I desire to 
direct the attention of the reader is, that the specimen does not sustain 
the claim made by certain advocates of this method, that it is able to 
prevent a shortening in all cases. In this case there is, according to 
the measurements made before death, a shortening of three-quarters of 
an inch. An examination of the specimen convinces me that it is some- 
what more ; but however this may be, one thing is certain, the limb 
shortened to the same degree that it would have done if no apparatus 
whatever had been employed. It shortened until the upper end of the 
lower fragment struck and was arrested by the neck. The apparatus 
enabled the patient to walk sooner than he could otherwise have done ; 
and this is a consideration of more importance often in an old man than 



FRACTURES OF THE SHAFT OF THE FEMUR. 465 

the length or form of the limb, and I doubt whether any other plan 
would have made the limb in this case any longer. 

Dr. John T. Hodgen, of St. Louis, in a paper on the " Value of Ex- 
tension in the Treatment of Fractures of the Femur," and especially as 
effected by his mode of suspension, speaks of the attempt to accomplish 
this by a plaster-of-Paris splint as a proposition too absurd to deserve 
serious consideration ; and in justification of this statement he has 
given several unanswerable anatomical and surgical facts. 1 

It will be necessary to describe a little more in detail than has been 
done in the chapter devoted to the general consideration of fractures, 
the method of applying the plaster of Paris in fractures of the thigh, 
which was formerly adopted at Bellevue. I say " formerly," because I 
have not seen it employed in any recent case at Bellevue during the 
last two years. Certainly if it has been employed, the practice is very 
exceptional. 

A plaster-of-Paris bandage is applied to the foot and leg some hours 
before the complete dressing is made. It is better that this should be 
done twelve or twenty-four hours before, in order that this portion of 
the apparatus may become solid, and not remain liable to be indented, 
or pressed inwards toward the limb when extension is applied, and also 
in order that the surgeon may know, by an examination of the toes after 
the lapse of a sufficient time, that the dressing is not too tight. 

This section of the apparatus should extend from a little above the 
metatarso-phalangeal articulation of the toes to about the junction of the 
middle and lower thirds of the leg. Instead of the soft woollen cloth, 
which is generally to be preferred in the upper part of the limb, we 
may here lay next to the skin a sheet of cotton batting, and this should 
be thicker over the instep and above the heel than elsewhere. We can- 
not take too many precautions in protecting the limb about the ankle 
from undue pressure. It will be remembered, also, that while at the 
ankle the splint should be thick, composed of five or six consecutive 
turns of the roller, it may be light upon the foot, and near the upper 
end of the splint upon the leg. 

While the dressings are being applied, and until they have hardened, 
the foot must be held carefully at a right angle with the leg, and in a 
proper line as to inversion or eversion ; but the assistant must take care 
that he does not, with his hand or fingers, indent the plaster. 

A temporary congestion of the toes almost always ensues upon the 
application of the bandage, but this usually subsides within twenty-four 
hours. If it does not, the bandage is too tight, and must be cut open. 

In applying the final dressings on the following day, or when the first 
dressing has become solid, the patient is laid upon a bed composed of 
two or three mattresses, or of a sufficient number of folded blankets, his 
loins, shoulders, and head resting upon the bed thus constructed, while 
his hips, thighs, and legs extend beyond the bed. In order to support 
the lower portion of the body in this position a piece of a cotton roller, 
three inches wide and two yards long, having been lubricated with sweet 
oil, is passed under the pelvis, and tied above to a bar supported by 

1 Hodgen, St. Louis Med and Surg. Journ., April, 1878. 



466 FRACTURES OF THE FEMUR. 

a stanchion, as seen in the woodcut (Fig. 181). Various methods of 
supporting the pelvis have been devised, but this is the most simple and 
efficacious. The piece of bandage is directed to be softened with oil, in 
order that it may .be easily withdrawn when the dressing is hard ; but if 
it has not formed a cord this may not be necessary, and it is sometimes 
cut off and left inclosed with the splint. 

The iron stanchion, wrapped with woollen cloth, is now brought against 
the perineum, and the pulleys made fast to the foot by a noose of cotton 
bandage. Moderate extension is made, sufficient to support and steady 
the limb, but not sufficient to overcome the shortening. 

The surgeon now wraps the limb, including the pelvis, thigh, and leg, 
down to the first splint, with soft but coarse woollen cloth, cutting out 
portions here and there, and fitting it smoothly to all the irregularities of 
surface, and stitching it loosely, when it is in place, over the region of 
the tuberosity of the ischium and perineum. Where the splint is liable 
to make undue pressure, two or three thicknesses of cloth may be placed, 
or cotton batting may be used instead. 

Everything being ready, the assistant places the patient completely 
under the influence of an anaesthetic, and then extension is made with 
the pulleys until the limb is restored, if possible, to the same length as 
the other. 

The bandages, filled with dry plaster, and previously soaked a few 
minutes in water, are then applied from below upwards, including, finally, 
the pelvis as high as the loins. At no point must they be drawn tightly, 
but only with sufficient firmness to insure their accurate adaptation to 
the limb. Three, four, or five thicknesses are required, according to the 
size of the limb, or the age of the patient. In front of the groin, where 
the splint is most liable to become, broken when the patient gets up, there 
should be laid two or three strips of binder's board, or narrow metal 
strips, tin or zinc. 

After each successive layer is applied, the surgeon will sprinkle a 
little dry powder upon the surface, and smooth it over with his hand 
previously dipped in water. As soon as the plaster is hard, usually 
within twenty or thirty minutes, the suspending apparatus is removed 
and the patient placed in bed. 

Those surgeons who omit to include the foot and ankle in the plaster 
splint do not, I think, avail themselves of the most important and most 
reliable means of making the little extension that can be made perma- 
nently in this form of dressing. When the limb shrinks the condyles of 
the femur and the calf of the leg offer very imperfect or no resistance to 
the action of the muscles of the thigh, and extension is completely lost. 
Let it be understood, also, that the author does not recommend that the 
perineum shall be made the point of counter-extension ; and in this he is 
sustained by the majority of those who have used this dressing ; and 
the shrinkage of the muscles of the thigh, which soon ensues, renders it 
equally impossible, ordinarily, to maintain permanently, against the only 
slightly conical surface of the upper portion of the thigh, any effective 
counter-extension. I think, with Dr. Hodgen, that the proposition is 
absurd, and I do not see how any really practical surgeon can enter- 
tain it. 



FRACTURES OF THE SHAFT OF THE FEMUR. 



467 



The patient can, in most cases, leave his bed by the third or fourth 
day after the splint is applied. If he keeps out of bed the limb will not 
shrink as much, and the necessity for readjustment will less often arise. 
But he cannot remain in the erect position all the time, and at the best 




Extension during application of plaster of Paris. 



there will be, as experience shows, opportunity enough for the limb to 
shrink, and for the apparatus to become loose. In case it becomes loose 
it cannot be refitted by cutting out a portion and folding the splint in 



Fig. 182. 




Extension continued until the plaster is hard. 



again, since it is too inflexible, and will not be made to bear upon the same 
points as before. At Bellevue, when a plaster dressing becomes loose it 
is always removed and a new one applied in the same manner as at first. 



468 



FRACTURES OF THE FEMUR. 



Finally, having considered somewhat at length the leading plans of 
treatment which have, from time to time, been suggested and employed 
by our best surgeons both at home and abroad, I desire to describe in 
greater detail those methods and forms of apparatus which my own ex- 
perience has taught me to prefer. 

As to posture, my opinions are in accord with the opinions of a vast 
majority of the most experienced surgeons of the present day. The straight 
position will, on the average, give the best results. Careful measure- 
ments made by myself in several hundreds of cases, a portion of which 
have been published in my statistical tables, 1 have demonstrated that the 
average shortening of the limb is greater after any method of treatment 
in which the flexed position is employed, than after treatment with ex- 
tension in the straight position. Whether this statement ought to include 
broken femurs treated by Dr. Hodgen's method I cannot say, since I have 
not measured many limbs treated by his method, and he has not given to 



Fig. 183. 



Fig. 184. 





Badly united fracture of femur ; treated 
without permanent extension. 



Fracture of femur just below trochanter minor. 



the profession any exact statistical record of his own results. I must, how- 
ever, state my conviction that the average results of these cases will fall 
a good deal short of the average results obtained, when proper extension 
is employed, in the straight position. These same carefully recorded 



1 Fracture Tables, by F. H. Hamilton, 1853. 



FRACTURES OF THE SHAFT OF THE FEMUR. 469 

observations, and my later observations have also shown that the flexed 
position, contrary to the reiterated statements of most of its advocates, 
is more apt to entail angular deformity. Fig. 183 is a fair illustration 
of what I have seen occur more than once when the flexed position was 
employed ; a condition which is impossible when proper extension is 
employed in the straight position. 

There are a few who, rejecting the flexed position in fractures of the 
middle of the shaft, still declare for this position a preference when the 
fracture occurs just below the trochanters, and in the case of fractures 
at the base of the condyles. 

According to Malgaigne, who has devoted especial study to this sub- 
ject, there is no satisfactory evidence in favor of the flexed position when 
the fracture occurs below the trochanters. It is not directly forwards, 
but forwards and outwards, that the lower end of the upper fragment is 
carried by the action of the psoas magnus and iliacus internus ; so that in 
order to meet the supposed indication it would be necessary to carry the 
lower part of the limb outwards also, a position which would certainly 
be found inconvenient, if not actually impracticable, in the majority of 
cases. Nor can the tendency of the upper fragment to advance in the 
forward direction, and consequently to separate from the lower, be met 
effectually by posture alone, unless the thigh is completely flexed upon 
the body. Indeed, it is apparent that the position of moderate flexion 
will rather favor the action of those muscles which are supposed to be 
chiefly responsible for the displacement. When the thigh is extended 
upon the body, the psoas magnus and iliacus internus are acting in the 
direction of, and nearly parallel to, the axis of the femur, and consequently 
to a disadvantage ; but when the limb is lifted, their action is more nearly 
at a right angle with the shaft, and their ability to displace the fragment 
is greatly increased. 

Moreover, it ought to be understood that broken bones are seldom or 
never displaced or separated, in the same manner they would be if they 
were not surrounded with many other structures which have suffered little 
or no disruption: they pass each other, but do not separate widely, being 
held together by shreds of periosteum, muscles, tendons, ligaments, etc. 
The same happens when this bone is broken just below the trochanters ; 
the upper fragment lies always, or almost always, in immediate contact 
with the lower, and whatever force is brought to bear upon the lower 
fragment more or less directly influences the upper ; we can then by 
extension applied to the leg, draw down not only the lower fragment, 
but we can drag into line the upper fragment. No doubt in this attempt 
we shall meet with some resistance from the muscles above named ; but 
experience has always shown that even moderate extension, applied 
steadily and without interruption, seldom or never fails to overcome, in 
a great measure, the resistance of the most powerful muscles. We con- 
stantly avail ourselves of this principle in overcoming the abnormal con- 
traction of muscles in connection with diseased joints, in the reduction 
of old dislocations, and in many other ways. 

Whatever the advocates of flexion in fractures of the femur may say 
to the contrary, they are never able in this position to employ effective 
extension and counter-extension. A careful examination of all the 
double-inclined planes which have been devised, including Nathan R. 



470 FRACTURES OF THE FEMUR. 

Smith's and Dr. Hodgen's suspending apparatus — I say it with all 
respect for these distinguished surgeons — it appears to me, ought to 
convince any experienced observer that such is the fact. Whatever 
other excellences they may possess, this does not belong to them. But 
extension is, of all the indications of treatment, that which is of the 
greatest importance in nearly all fractures of the thigh, and no less 
important in the upper third than in the lower. Indeed, it is of more 
importance in case of a fracture through the upper than in the case of a 
fracture through the lower third, since, as my measurements have shown, 
the higher the point of fracture the greater is the tendency to shorten, 
in consequence of the action of those powerful muscles which, arising 
above, have their insertions into the lower fragment. 

In the case of all those double-inclined planes where the body rests 
upon a bed, there can be no counter-extension except the weight of the 
pelvis and its contents. It will not do to fasten the pelvis to the bed by 
bands, as every one who chose to make the experiment would soon learn; 
nor will the groin tolerate the pressure of counter-extending splints or 
bands. These things have been tried in a thousand ways, and aban- 
doned. The weight of the pelvis alone, not of the entire body, is the 
only counter- extending force which can be made available in these forms 
of apparatus, and this is wholly insufficient. In Nathan R. Smith's 
anterior suspension splint, not even the weight of the pelvis is employed 
as a means of counter-extension, the pelvis being secured to the splint 
by rollers, equally with the thigh and leg, and there is no possible chance 
for extension and counter-extension. 

After all, I prefer to leave this question to the verdict of experience, 
and happily this seems to be conclusive, if we may accept the almost 
unanimous testimony of those surgeons who have enjoyed the largest 
hospital practice. In my own experience the ordinary double-inclined 
planes have constantly given the worst results, both in regard to length 
and lateral displacement ; they are the most difficult to manage, and 
are the most fatiguing to the patients. Nathan R. Smith's suspending 
apparatus permits the limb to shorten indefinitely ; and it affords inade- 
quate support along the centre of the shaft, in consequence of which the 
limb is apt to unite with a backward curvature or angle. In some gun- 
shot fractures treated by this apparatus this posterior curve or angle has 
been excessive. 

Even the old methods of extension were preferable to flexion ; but 
they had always two serious drawbacks. First, in the excoriations and 
ulcerations incident to the application of extending bands or gaiters, or 
whatever else was employed for this purpose. Again and again I have 
seen ulceration of the instep, of the integuments above the heel, and of 
other parts of the foot and ankle, from extending bands. And, second, 
from similar excoriations, ulcerations, and deep sloughs about the groin 
and perineum, caused by the counter-extending band. It is true these 
accidents did not occur often, and sometimes they were due wholly to 
negligence ; but, in order to avoid them, we were compelled to limit 
very much the amount of extension, and to exercise unceasing vigilance. 
At Bellevue, as I have elsewhere reported, an attempt was made to em- 
ploy counter-extension in the perineum of an adult, by plaster of Paris 



FRACTURES OF THE SHAFT OF THE FEMUR. 471 

applied in the usual manner for a broken femur, and as a consequence 
a perineal slough was soon formed two or three inches in depth by 
several inches in length. Lente, the Burges, myself, and others sought 
to overcome some of the difficulties of the perineal band by various con- 
trivances ; and perhaps in some measure we were successful, but still 
the danger of ulceration existed wherever much force was employed, or 
the integuments were unusually delicate. Gilbert's plan of substituting 
adhesive plasters for the usual counter-extending band, in the perineum, 
and Buck's plan of employing elastic tubing, possess no real advantages. 
The truth is, there is no point about the groin, perineum, or pelvis upon 
which, by one surgeon or another, the pressure has not been made, and 
more or less distributed, for the purpose of counter-extension ; and there 
is no possible method, perhaps, which has not been employed ; yet, after 
a fair trial, the results are the same. The pressure must be moderate, 
or serious accidents will occasionally happen. 1 

Hodge's attempt to make the counter-extension from the sides of the 
trunk by strips of adhesive plaster, as already described, is w T holly ineffi- 
cient. They will loosen inevitably in a few T hours. 

Our first great step of progress in the treatment of fractures of the 
thigh — first in importance, but not in order of discovery — consists, then, 
in having secured counter-extension by the weight of the body alone, 
and this is accomplished by simply elevating the foot of the bed from 
four to six inches. I have not used a perineal band, except in cases of 
children, for twenty years ; and, in the case of children, the weight of 
the body is still my chief reliance. None of my colleagues at Bellevue 
use the perineal band to-clay. 

The first to suggest and practise this was Dr. James L. Vaningen, of 
Schenectady, New T York. (We shall see hereafter that Dngas attempted 
to make counter-extension by the weight of the body at a still earlier 
period, but he did not elevate the foot of the bed.) His method was 
reported to me, probably, in 1855, and was published in 1857, in con- 
nection w T ith my Beport on Deformities after Fractures, in the Transac- 
tions of the American Medical Association, accompanied with three 
woodcuts for the purpose of illustration. The foot of the bedstead was 
much more elevated than has been found necessary in later experience. 
It is interesting to note, however, as evidence, that Dr. Vaningen had 
practical experience with this method, that he directed especially that 
the pillow should be kept under the head only "so as to keep the neck 
and shoulders quite free." 2 According to the statements of Dr. Bobert 
F. Weir, of this city, Dr. Buck first elevated the foot of the bed for the 
purpose of making counter-extension, in 1859, while Dr. Weir was an 
interne of the New York City Hospital. 3 Dr. Buck first publicly 
described his method in a communication to the N. Y. Academy of 
Medicine in 1861. 4 

The second step was the employment of the weight and pulley as a 
means of extension. I am indebted to Dr. Martin, of Boston, for the 

1 For cases of sloughing, etc., from perineal band, see N. Y. Journ. of Med., vol. 
xiv., 2d ser., p. 261, March, 1856 ; also same journal, Jan. 1840, p. 239. 

2 Vaningen, Trans. Am. Med. Assoc, 1857, pp. 436-7. 

3 Med. Record, March 9, 1878, p. 181. 4 Amer. Med. Times, March 30, 1861. 



472 FRACTURES OF THE FEMUR. 

evidence that this method of making extension was known to Hildanus, 
in the 16th century, although it seems to have passed very much into 
disuse until recently revived by American surgeons. 1 John Bell, in his 
Principles of Surgery, published at Edinburgh in 1801, speaking of a 
method described by Hildanus, says : " But surgeons did at last fall upon 
a method which absolutely insured the permanent extension. For being 
wearied with this perpetual turning of screws to tighten the bands 
around the ankle, they at last most happily thought of putting a pulley 
to the foot of the bed, and hanging a good jack-stone to the heel. I have 
(in next page) drawn the bed, the surcingle or horse-girth for the body, 
and the jack-stone of Hildanus for hanging to the heel, and, according to 
my poor conception, the method of permanent extension was by this ren- 
dered so perfect, that Mr. Desault could do nothing but disgrace himself 
by attempting any farther improvement." . . . "If this girth do 
not" "prevent the body from gravitating toward the fractured limb, if 
the jack-stone do not prevent the limb being detracted towards the body," 
" there must be something in the theory and practice of Mr. Desault 
passing all comprehension." 

In the above description we see a full recognition of the value of 
the pulley and weight, but the body was prevented from descending by 
being tied to the bed, and the extension was made by a garter. We 
need not be surprised, therefore, that the pulley and weight under these 
disadvantages were soon laid aside and forgotten. Guy de Chauliac, Sue- 
tin, and Nathan Smith, according to Malgaigne, 2 employed occasionally 
the pulley and weight. Boyer says the practice is very ancient. Dr. 
Wm. C. Daniell, of Savannah, Georgia, treated a case in this manner in 
1819, and again in 1824, the latter of which he published. The ordi- 
nary perineal band and a garter were used for counter-extension and 
extension. 3 In 1854, L. A. Dugas, of Savannah, Georgia, published an 
account of the method employed by himself, with an illustration. 4 This 
illustration, with a brief explanation of the mode of using the apparatus, 
was republished in my report to the American Medical Association in 
1857, pp. 434-5, and again in the first edition of this treatise published 
in 1860. Dr. Buck's communication to the Academy of Medicine con- 
tains no allusion to this plan of Dugas, but in his illustrations of his own 
method the small cannon-ball is used as a weight precisely as in Dugas. 
I do not mention this as an evidence of unfairness on the part of Dr. 
Buck, but only to indicate that he had probably seen Dr. Dugas's wood- 
cut. Dr. Buck had evidently intended to combine several improvements, 
for no one of which has he claimed the original conception. 

Dugas used a piece of bandage as his means of applying extension ; 
but he omitted the perineal band, which had not been done by Buck 
when he first made public his own method. Dugas relied upon the weight 
of the body to make counter-extension, saying that" the resistance of the 
patient's body will effect counter-extension;" a statement which later 
experience has shown to be not correct, unless, as first recommended by 
Vaningen, the foot of the bedstead is somewhat raised. 

1 Martin, N. C. Med. Journ., Feb. 1878. 2 Malgaigne, Packard's Trans., p. 197. 

3 Daniell, Amer. Journ. Med. Sci., vol. iv. p. 330. 

4 Southern Med. & Surg. Journ., Feb. 1854, p. 69. 



FRACTURES OF THE SHAFT OF THE FEMUR. 473 

The third great step of improvement, and that which alone makes ade- 
quate extension, in most cases, possible, was the substitution of adhesive 
strips, laid along the whole length of each side of the leg, in place of the 
garter. Of this, also, we are no longer permitted to speak as a novelty, 
the researches of Dr. Martin, already referred to, having brought to 
light the following paragraph in the works of Dr. Gooch : — 

" To answer the same purpose, I have confined one end of a strong 
strip of sticking plaster, of a suitable length and breadth, under a circu- 
lar piece of the same, about the middle of the side of the foot, carrying 
it over the heel, up the leg, and confining the other end above the calf 
with another circular plaster, first, gradually bring down the muscul. 
gastrocnem. as far as they will readily yield ; giving the limb, at the same 
time, the position described in my treatise on wounds. On the like 
occasion, I have also fixed one strap by the circular about the foot, and 
another by that above the calf of the leg, passing the one through a slit 
in the other, and using them as the uniting bandages ; but then two more 
circulars are requisite to confine the other ends of the longitudinal straps 
securely." 1 

This also, like extension by a pulley and weight, seems to have been 
forgotten until revived by some American surgeons. The first allusion 
I find to it in recent literature is by Dr. F. W. Sargent, of Philadel- 
phia, in 1848, who says he derived the suggestion from Dr. E. Wallace, 
of Philadelphia, by whom they were used successfully while he was the 
Resident Surgeon of the Pennsylvania Hospital. Both of these gentle- 
men used long strips of adhesive plaster, of an inch or more in width, 
carrying them spirally down the leg from a point about midway between 
the foot and knee, after which they were, in some cases, made secure 
with rollers. 2 

In the third volume of the Transactions of the American Medical As- 
sociation (1850) the same method is described as being recommended by 
Dr. Josiah Crosby, of New Hampshire, the only difference being that 
he carried the adhesive plaster as high as the knee. 3 In this brief notice 
of Dr. Crosby's plan, the editor remarks that Dr. Sargent had in his 
Minor Surgery described essentially the same, as being first practised 
by Dr. Wallace. Vaningen suggested the same in connection with the 
elevation of the foot of the bed, in 1857, as will be seen by refer- 
ence to my reports, before referred to,. Dr. Buck spoke of it publicly 
in his communication to the Academy of Medicine in 1861. 

Of the claims instituted for Dr. Mosely, of New Hampshire, who says 
his use of these strips dates back to 1840, and the like claims of Gross, 
Swift, Ennis, and others, we can only say they were unfortunate in not 
earlier giving their views and practice to the public. 

Finally, it is by the combination of these three essential principles 
with the short side splints and one long side splint, which shall reach 

1 "Medical and Chirurgical Observations as an Appendix to a former Publication, 
by Benjamin G-ooch, Surgeon, London, printed for Gr. Robinson, in Pater Noster Row, 
and R. Beatniffe, in Norwich." No date, but about 1771. N. C. Med. Journ., Jan. 
1878, Martin. 

2 Minor Surgery, by F. W. Sargent, M.D., Lea & Blancbard, Philadelphia, 1848. 
8 Crosby, Trans. Am. Med. Asso., vol. iii. 1850, p. 383. 

oi 



474 



FRACTURES OF THE FEMUR. 



from near the axilla to beyond the foot, to prevent the outward bowing 
of the thigh and to prevent eversion of the leg, that the superiority of 
extension in the straight position can alone be demonstrated. The long 
outside splint, which I have myself added to the apparel, is only second 
in point of importance with either of the others, and that whether the 
fracture be in the neck or the shaft, in children or in adults. In chil- 
dren, however, it is supplied by the double splint. 

With regard to fracture beds which, when surgeons adopted the flexed 
position in the treatment of fractures of the thigh, were often very use- 
ful and sometimes necessary, I must say that, in the treatment of these 
fractures in the extended position, they are not needed. We never use 
them for this purpose at Belle vue, nor do I think they are used at any 
hospital in this city. If the bed is sufficiently long and the mattress is 
smooth, firm, and even, nothing more is required. Properly shaped bed- 
pans can always be used without disturbing the limb, and the arrange- 
ments for changing the position of the limb are not only useless, but 
such changes are actually injurious. Inasmuch, however, as in certain 
complicated cases of fracture of either the thigh, leg, or foot, adjustable 
or movable " invalid" beds may be needed, when extension is not to be 
attempted, I shall see fit to allude to a few of those which are best known 
among American surgeons. 

As invalid beds, the best known and most ingenious American con- 
trivances are those invented by Jenks, 1 Daniels, the Burges, Addinell 
Hewson, of Philadelphia, 2 J. Rhea Barton, B. H. Coates, of the same 
city, 3 and J. Crosby, of Manchester, N. H. 4 

Fig. 185. 




E. Daniels's invalid bed. 8 



In my earlier practice I have had constructed a simple frame, covered 
with a stout canvas sacking, having a hole at a point corresponding with 



1 Jenks, Gibson's Surgery ; also the 5th ed. of this treatise, Fig. 185, p. 

2 Hewson, Amer. Journ. Med. Sci., July, 1858, p. 101. 

3 Eclectic Repertory, 5th and 9th vols. 

4 Crosby, Treatise on Milit. Surg., by Frank H. Hamilton, 1865, p. 413. 



445. 



See also Figs. 186 and 189 of 5th ed. 



FRACTURES OF THE SHAFT OF THE FEMUR 



475 



the position of the nates, and this I have laid directly upon a common 
four-post bedstead. A mattress and one or two quilts must be placed 
upon the boards of the bedstead underneath the sacking, and a sheet or 
two above the sacking, upon which last the patient is to be laid. In 



Fig. 186. 




•Tcfioss.se. 



Crosby's invalid bed, closed. 



arranging the linen underneath the patient, the most convenient plan is, 
instead of using only one sheet, which will require that a hole shall be 
made in it corresponding to the hole in the sacking, to employ two sheets, 



Fig. 18"; 




Crosby's invalid-bed, open. 
The bed is movable, and can be run out from under the patient and changed. It is then run back, 
the hooks B being made fast to the catches A. By turning a crank at C, the rail D is revolved, which 
winds up a strap passing over the pulley G, and the bed is raised to its position, thus taking off the 
weight of the patient from the bands by which he was temporarily suspended. 

and, doubling them separately, to bring the folded margin of each from 
above and from below to the centre of the opening. When the patient 
has occasion to use the bed-pan, it is only necessary that two or four 
persons should lift this frame, and place under each corner a block about 



476 



FRACTURES OF THE FEMUR 



Fig. 188. 



one foot in height, or it may be raised by a pulley and ropes suspended 
from the ceiling. 

My usual practice now, in a private house, is to remove the foot-board 
and lengthen the bed by boards laid longitudinally, and projecting one 
or two feet beyond the bottom rail. This furnishes a firm support for 
the mattress. Sometimes, of course, it will be found necessary to 
lengthen the bed. No hole is made in the flooring of the bed or of the 
mattress, to provide for fecal evacuations. 

A very comfortable bed, especially for children, can sometimes be 
made from a cot. But it will be necessary always to nail a piece of 
board firmly across the top and bottom of the bedstead when the sacking 
is at its utmost tension, in order to prevent the side rails from falling 
together. The top board must be nailed on vertically, like an ordinary 
head-board, so as to prevent the pillows from falling off, but the bottom 
piece should be at least one foot wide, and laid horizontally to support 
and steady the apparatus as it extends beyond the foot. 

Having had occasion to assist the late Dr. Treat in the management 
of a fracture of the thigh in the case of a little girl not quite three years 
old, I was struck with the simplicity and completeness of an 
arrangement which he had made to prevent the bed and the 
dressings from becoming soiled with the urine. It was 
only to leave directly underneath the nates a complete 
opening through to the floor for the escape of the urine, and 
to protect the margins of the sacking and sheets, which 
came nearly together at the opening, with pieces of oiled 
cloth folded upon themselves. It was found that not only 
the bed was in this way kept dry, but the dressings also ; it 
being now observed that the dressings had become wet here- 
tofore by soaking up the moisture from the bed, rather than 
by the direct fall of the urine upon them. 

Having prepared the bed for the reception of the patient, 
and elevated its lower end about four inches by placing 
blocks underneath the foot-posts, the following additional 
preparations should be made before we proceed to reduce 
the fracture and dress the limb : — 

There should be provided a piece of board of the requisite 
length and breadth, furnished with a slot to receive the pul- 
ley, and called the " standard," a small iron rod, a pulley, 
a yard of rope, and a vessel or bag to receive the weights. 
The slot should have sufficient length, and the standard should be 
perforated in the direction of its breadth at short distances, to enable 
the surgeon to elevate or depress the pulley, as may be required. In 
case a metallic pulley cannot be obtained, a spool will answer as a tol- 
erable substitute. We now employ generally, at Bellevue, an iron up- 
right rod, with a pulley affixed, and which is made fast to the iron 
frame of the bedstead with two iron clamps, secured in place by screws. 
They may be found at the shops of any of our instrument makers. A 
pulley, mounted with a screw, may be sometimes substituted, the screw 
being attached to the foot-board. (Fig. 189.) 

The adhesive plaster which I have generally used both in private and 



Standard. 



FRACTURES OF THE SHAFT OF THE FEMUR. 



477 



soft, and firmly adherent," 
"foot-piece," is to be pro- 



Fig. 189. 



hospital practice is that which is usually found in drug stores, spread 
upon linen ; but some of my colleagues prefer the plaster spread upon 
jeans or canton flannel, as being stronger. I cannot, however, appreciate 
their advantage, since the ordinary plaster seldom gives way when 
properly applied. Dr. John B. Brooke, of Reading, Pa., prefers the 
" ordinary pitch plaster," as being " elastic, 
and as not excoriating, etc. 

A thin block or piece of board, called the 
vided, perforated in the centre to receive the 
cord, and of sufficient length to prevent the 
adhesive strips or " extension bands" from 
pressing upon the malleoli. An average 
size for the foot-piece in the case of an adult 
is about three inches and three-quarters in 
length, by two and a half in breadth. 

The adhesive plaster maybe cut in the shape 
shown in the illustration (Fig. 191) : five and 
a half inches wide in the centre, and two and 
a half inches wide at the narrowest point, 
and gradually widening again toward each 
extremity to four inches ; the narrower por- 
tions being slit down two-thirds of their 
length. For an adult we generally require 
a strip of about four feet and eight inches in 
length, namely, sixteen inches for the cen- 
tral and widest portion, and twenty inches 
for each extremity. The shoulders of the 
central portion are cut as represented, in 
order that when folded upon the foot-piece and upon itself it may rein- 
force the lateral bands at their weakest points. 

The lateral or side-splints may be made of thick pieces of gum shellac 
cloth, of stout leather cut and moulded to the limb, or of thin pieces of 
board covered with cotton cloth and stuffed on the sides next to the skin 
with cotton batting to fit all the in- 
equalities of the limb. Of these 
several materials gum-shellac cloth 
is much the best. It is thin, light, 
firm, and after immersion in hot 
water can be sufficiently moulded * 
to the contour of the thigh. The 
cotton cloth must be stitched over 
the splints like a sac, but left open 
at the ends until the padding is 
properly adjusted. Loose cotton 
batting always becomes displaced. Four splints are generally required: 
one for the anterior surface, extending from the groin below the anterior 
inferior spinous process of the ilium to within half an inch of the patella ; 
one for the posterior surface, extending from the tuberosity of the ischium 
to a point six or eight inches below the knee ; one for the inside, extend- 
ing from near the perineum to the inner condyle ; and one for the out- 




iron upright and weight. 
Tiemaun.) 



(From 



Fig. 190. 




Foot-piece. 



478 



FRACTURES OF THE FEMUR. 



side extending from above the trochanter major to the outer condyle. 
These splints ought to encircle the limb almost completely, only leaving 
an interval of from half an inch to one inch between each of the adjacent 
splints. The outer and inner splints may be extended below the knee 



Fro. 191. 




Extension-baud and foot-piece. 




when the fracture is low down ; but in that case they must be carefully 
fitted to the irregularities of the condyles. The posterior splint is the 
most important of them all. It should be wider and much longer than 
either of the other splints, and it must be fitted with great accuracy to 



Fig. 192. 




Same, folded and ready for u 



the back of the thigh, ham, and upper part of the leg. It is important 
also to cover this with a sac of cotton cloth so that it may be stitched to 
the centre of the bands, which are to inclose all the splints. If this is 
not done, it is very liable to become displaced. 

A long side-splint must now be prepared, long enough to extend from 
about four inches below the axilla to five inches below the heel ; four 
and a half inches wide, by half an inch in thickness, and provided with 
a cross-piece at the lower end, two feet long by three inches wide and 
half an inch thick. The purpose of this splint is not to make extension, 
but to prevent the femur from becoming bent outwards at the seat of 
fracture ; which is accomplished more certainly by this splint than by 
the short splints, inasmuch as it keeps the whole body, including the 
upper part of the femur, in a straight line. Its purpose is also to pre- 
vent eversion of the foot, which purpose is never accomplished effectively 
by junks or by any other method I have yet seen adopted. It is to be 
employed in all fractures of the thigh, including fractures of the neck. 
The inner surface of this long splint must be padded through its whole 
length, and thus fitted accurately to the sides of the body and limb. 

Four or six strips of cotton cloth, each two inches wide by one yard 
in length, are stitched by their centres to the outer surface of the back- 
splint, and these are laid upon the bed in position for the splint to receive 
the limb. 

Supplied with rollers, several additional strips of bandage, and cotton- 
batting, we are now ready to reduce and dress the fracture. 

The patient being placed in position upon the bed, one assistant 
seizes the limb by the knee, and a second by the foot, drawing upon it 
firmly and steadily ; while the surgeon lays the extremities of the ex- 
tension strip upon each side of the leg, with the centre, containing the 
foot-piece and the rope, about one inch below the sole of the foot. 



FRACTURES OF THE SHAFT OF THE FEMUR 



479 



With a muslin roller, inclosing the limb from near the metatarsopha- 
langeal articulation to the tuberosity of the tibia, the adhesive strips 
are held in place. As a rule, and especially in the case of women, and 
of persons of a delicate lax fibre, it is well to lay against the tendo 
Achillis, and over the instep, a little cotton-batting before applying the 
roller. In some cases I am in the habit of applying a thin sheet of 
cotton-wadding over the whole surface of the limb. Any excess of 
the bands at the upper end is disposed of by turning the ends down, 
and inclosing them in a few additional turns of the roller. As soon as 
the application of the adhesive strip and roller is completed, the weight 
may be adjusted, and extension applied. The amount of extension 
required for adults will vary from eighteen to twenty-three pounds. In 
a large proportion of cases, twenty or twenty-one pounds will be borne 



Fig. 193. 




Mode of applying adhesive plaster. (When the dressings are completed, the limb is to rest on the bed.) 

without complaint ; and the ability of the patient to tolerate the exten- 
sion, alone limits the amount. Occasionally, even a few pounds, when 
first applied, causes pain in the ligaments about the knee-joint ; but in 
a few hours the amount may be increased. It is better to apply eighteen 
or twenty pounds at once, if it can be borne. Lifting the knee slightly 
by a pad placed underneath will often relieve the pain caused by the 
extension. 

Sometimes, in the case of very muscular patients, and where the 
primary shortening is considerable, I believe we make a positive and 
permanent gain if we place the patient under the influence of chloro- 
form for a few minutes, when the weight is first applied. In these 
cases, as in dislocations, I generally prefer chloroform to ether, for the 
reason that the patient is less liable to muscular contractions when he is 
passing under the influence of the anaesthetic. 

Extension being effected, and the patient already resting upon the 



480 



FRACTURES OF THE FEMUR. 



posterior coaptation splint, the three other side-splints are applied, and 
the whole four secured in place by the four or six transverse bands 
already described as attached to the posterior splint ; the bands being 
tied over the front splint firmly. 

It remains only to lay the long splint beside the body, and to secure 
it in place by separate strips of bandage. Three strips for the leg, one 
broad strip for the pelvis, and one for the chest are all that are required. 
The leg strips may be drawn pretty firmly to prevent all outward rota- 
tion of the limb. The pelvic band also ought to be tight to insure the 
constant contact of the pelvis with the long splint ; but the thoracic band 
may be rather loose, as its function in this respect is not so important. 
Both of the latter bands should be sewed to the cover of the long splints 
to prevent their becoming displaced. In the drawing (Fig. 194), similar 
strips inclose the thigh, but I often omit them as being unnecessary ; 
indeed, it is better sometimes to omit them, when the fracture ishigh 
up, lest they should hold the lower fragment out, when the pelvis was 
not firmly secured to the long splint ; in which case the upper fragment 
might incline in the opposite direction, causing thus a bowing out at the 
point of fracture. 

The patient's pillow must rest under the head alone, in order that the 
whole weight of the body, from the shoulders down, may be employed 
as a means of counter-extension. Omission of this important precept 
will sometimes permit the body of the patient to descend toward the foot 
of the bed, even when the foot of the bedstead is raised. 

Fig. 194. 




Author's dressings for fracture of shaft of femur, complete. (The long splint extends nearly to the 
axilla, and is confined to the pelvis and chest by two broad bands, not shown in the drawing.) 



During the first four or five weeks the patient should not be allowed 
to rise or to sit up in bed. It is an error to suppose that such restraint 
is irksome. In my experience, no patient has ever complained of it; 
and I have no doubt that such movements increase the danger of non- 
union ; a misfortune which has never happened when a patient has been 
under my treatment from the first to the last. I have, however, seen 
several cases of non-union, or of delayed union, in the practice of other 
surgeons, which I attributed to the patient having been permitted to rise 
in bed. For this reason, also, I reject all modes of treatment which are 
intended to permit these motions of the body, such as Burges's fracture- 
bed. 

In order to evacuate the bowels, the patient may draw up the sound 



FRACTURES OF THE SHAFT OF THE FEMUR. 481 

limb, when a properly-constructed bed-pan is easily placed under the 
nates. This occasions no disturbance to the fracture. 

From the time of the first dressing the patient should be seen daily, 
and the coaptation splints loosened or tightened from time to time, as 
may seem necessary. To open the limb, and even to remove tempora- 
rily all the coaptation splints except the posterior one, is harmless, and 
it is often a source of comfort to the patient. Ordinarily it is not ne- 
cessary or prudent to disturb the extension until the union is completed. 
The usual time required for consolidation in the case of an adult is from 
six to eight weeks ; but if the bone feels pretty firm at the end of four 
weeks, the extension may be a little relaxed. When at length the 
patient is permitted to leave his bed, a pair of crutches is indispensable ; 
and during the following two months but little weight should be borne 
upon the limb. 

Fractures of the thigh in children have generally been found more 
difficult to manage than fractures of the same bone in the adult, owing 
chiefly to the shortness of the limb, the delicacy of the skin, and the 
restlessness of the patient. I have tried nearly all forms of apparatus 
in these cases, including double-inclined planes, boxes, single long splints, 
etc., and the result of my experience is that they are all inefficient ; and 
for some years I have employed a mode of dressing, partly my own and 
partly the suggestion of others, but of which I am able to say that it 
never disappoints me in the result obtained ; while it is simple, easy of 
management, and comfortable to the little patients. 

Extension by means of adhesive plaster and a weight employed in 
the same manner as in adults, constitutes a valuable aid in many cases ; 
but I cannot say that it is indispensable, since, with children under five 
or seven years, the fractures are pretty often so nearly transverse that, 
when once reduced and well supported by lateral splints, union without 
shortening may generally be expected ; but these results become less 
and less frequent as we advance toward adult life. It is safe and pro- 
per, according to my experience, to employ in any case extension, some- 
what according to the following rule. One pound for a child one year 
old, two for a child two years old, and so on, adding one pound for every 
year up to the twentieth. Of much more consequence, however, is it to 
confine, at the same time, both limbs, for as long as one is at liberty it 
is almost impossible to secure any degree of quiet. It is of equal im- 
portance, in my opinion, to give to the limbs an extended rather than a 
flexed position. 

My plan of treatment, therefore, in the case of children, is in all 
essential respects the same as in adults, except that instead of one long 
side-splint, I employ two. The accompanying illustrations will explain 
more fully my meaning. Two long side-splints connected by a cross- 
piece at the lower ends, and reaching upwards to near the axillae, sepa- 
rated a little more widely below than above, so as to render the perineum 
more accessible, are laid upon each side of the body. The leg of the 
broken limb is secured to the long splint with a roller. The remainder 
of the limb, the opposite limb, and the body, are made fast with broad 
and separate strips of cloth. The coaptation splints, in the case of 
children, may be made of binder's board. 



482 



FRACTURES OF THE FEMUR 



Thus secured and laid upon a bed, such as I have already described 
as appropriate for children, the least possible annoyance will be given 
to the surgeon. The dressings are but little liable to become wet with 
urine, and when the bed is soiled, the child can be taken up with the 
splint and carried to another ; indeed, this may be done as often as the 
patient becomes restless or weary, without any risk of disturbing the 
fracture. 

Fig. 195. 





Author's splint for fracture of the femur in children. 
Fig. 196. 




Author's dressing for fracture of the femur in children, complete. 

In case the surgeon desires to use extension with adhesive plaster 
and weights, the necessary apparatus may be made fast to the bedstead, 
and taken off when the child is moved ; or it may, if thought best, be 
made fast to the foot-piece of the splint. 

Occasionally, with children, I employ, as a means of extra safety, a 
perineal band, drawn moderately tight, and fastened to the top of the 
splint on the side corresponding to the broken limb. The best perineal 
band is a piece of soft cotton cloth, one or two yards long by three 
inches wide, folded lengthwise to a flat band of one inch in breadth, 
and inclosing, where it passes through the perineum and under the 
nates, a few thicknesses of paper. The paper prevents its drawing into 
a round cord. Sometimes I place between the paper and the folded 
cloth, on the side which is to be laid next to the skin, one or two thick- 



FRACTURES OF THE SHAFT OF THE FEMUR. 483 

nesses of cotton wadding. To absorb the moisture, it is well to lay a 
piece of sheet lint between the band and the skin. The perineal band 
may be removed daily and renewed ; and the perineum examined and 
washed. 

Four or five weeks is generally a sufficient length of time for perfect 
consolidation, in children under five years of age. 1 

If I have been unable to give my approval to the treatment of frac- 
ture of the shaft of the femur in adults with plaster of Paris, or to any 
other form of immovable dressing, I am still less able to give it my ap- 
proval in fracture of the same bone in children. The following case will 
illustrate its dangers : A boy, four years old, fell thirty feet, breaking 
his right thigh near its middle, causing one of the fragments to protrude 
through the flesh. The surgeon in charge, having reduced the fracture, 
applied on the fifth day a plaster of Paris splint from the toes to the 
groin, leaving a fenestra opposite the wound in the thigh. The child 
suffered much pain that night, and on the following morning his toes were 
cold. On the second morning after the dressing there were vesications 
on the toes. On the fourth day the toes were discolored, and an offen- 
sive odor escaped from the dressings. The dressings were now removed, 
and the toes, with a part of the foot, were found to be gangrenous. 
Subsequently, the gangrene extended to the middle of the leg. This 
case had been seen and the condition of the toes noted each day by the 
surgeon, but he did not become alarmed until the fourth clay. The sur- 
geon in attendance was then dismissed and another called, by whom I 
was immediately consulted, at my house, as to the proper course to be 
pursued. I advised the continuous hot water bath as preferable to am- 
putation under the circumstances, in accordance with my published ex- 
perience in numerous cases of traumatic gangrene. 2 The surgeon adopted 
my suggestion, and in about three weeks the limb separated spontane- 
ously, the gangrene having never extended after the limb was submerged 
in the bath. His recovery has been complete. 3 

The treatment of compound fractures of the thigh, caused by gunshot 
injuries, will be considered in the chapter devoted to gunshot fractures. 
Other badly comminuted and compound fractures of this bone are to be 
managed upon the same general principles as gunshot fractures. 

Those compound fractures of the femur which have been caused by 
the thrusting of the sharp fragments through the flesh, and in which re- 
duction has been easily effected, have in most cases done as well as 
simple fractures, except that the limb is generally a little more shortened. 
The wound usually soon heals, and the future progress of the case is the 
same as that of a simple fracture. They may be treated, therefore, in 
the same manner as those which have just been described. 

1 Fractures of Shaft of Femur in Children. A clinical lecture by the author at 
Bellevue, Med. Rec, Jan. 5, 1878. 

2 Warm and Hot Water in Surgery. By my late pupil, Dr. Fred. E. Hyde. Buf. 
Med. Journ., Dec. 1875; Trans. N. Y. State Med. Soc, 1875 ; Richmond and Louis- 
ville Med. Journ., Jan. 1874 ; New York Med. Rec, May 15, 1874, with various other 
papers by the author. 

3 Medical Record, March 15, 1879, p. 257, case reported by Dr. Forest. 



484 



FRACTURES OF THE FEMUR. 



Fig. 197. 



§ 5. Fractures of the Shaft, at or near the Base of the Condyles. 

These fractures are not so common as fractures of the shaft elsewhere. 
Only twenty examples are contained in my records as having come un- 
der my personal observation. Malgaigne thinks they are caused gene- 
rally by direct blows, but this was not Sir Astley Cooper's opinion, and 
according to my own experience they are caused generally by a fall upon 
the knees or feet. In at least nine of the cases seen bv me the fracture 
was caused in this manner, and in seven it is known that the fracture 
was caused by a direct blow. 

The direction of the line of fracture is generally from behind forwards 
and downwards, the upper fragment being driven downwards toward the 
patella ; in other cases the line of fracture preserves the same general 
direction, but inclines inwards or outwards ; and in these cases the upper 
fragment is found lying more or less on the inner or outer margins of the 
knee, probably most often on the inner side. 

In one instance I have found both femurs broken at the same point 
and in the same manner. Mr. L. Brittin, aged about fifty-five years, 
wdiile employed upon a building, fell from a fourth-story window upon 
the stone pavement below, striking upon his feet. In addition to several 
other fractures, I found both femurs broken obliquely downwards and 
forwards, just above the condyles. Very little inflammation ensued, 
and although it was found impossible to employ extension, union occurred 
readily, and with only a moderate overlapping. 
In the left limb, however, the upper fragment 
pressed down sufficiently to interfere somewhat 
with the patella, and the patient was unable, 
after several months, to straighten the knee 
completely. The motions of the right knee 
were unimpaired. 

I have only once met with a fracture at 
this point in which the line of separation was 
downwards and backwards. As the case pre- 
sents several points of interest, it will be 
proper to narrate the facts somewhat at length. 
George Taylor Aiken, of Lockport, N. Y., 
set. 7, on May 18, 1854, in jumping down a 
bank of about three feet in height, broke the 
right thigh obliquely, just above the knee-joint. 
Direction of the fracture obliquely downwards 
and backwards. 

Dr. Gr., an accomplished surgeon, residing 
in Lockport, was called. The limb was not 
then much swollen. He applied side splints, rollers, etc., carefully, and 
then laid the limb over a double-inclined plane. The knee was elevated 
about six or eight inches. Before applying the splints, suitable exten- 
sion had been made, and after completing the dressings, the two limbs 
seemed to be of the same length. 

On the second or third day, Dr. G. noticed that the toes looked un- 
naturally white, and were cold. 




Fracture at base of condyles. 



FRACTURES OF THE SHAFT AT THE CONDYLES. 485 

Counsel was now called at the request of Dr. G., when it was deter- 
mined to abandon all dressings, and direct their efforts solely to saving 
the limb. 

The result was that slowly a considerable portion of his foot died and 
sloughed away, leaving only the tarsal bones. The fracture united, 
but with considerable overlapping and deformity. 

Feb. 26, 1856, the boy was brought to me by his father. On exam- 
ining the fracture, I noticed that the anterior line of the femur seemed 
nearly straight, and this appearance was owing in some degree to the 
muscles which covered and concealed the bone, and in some degree, 
also, to the manner in which the fragments rested upon each other ; the 
pointed superior end of the lower fragment resting snugly upon the 
front of the upper fragment, so that no abrupt angle existed in front. 
On the back of the limb, however, the lower end of the upper fragment, 
quite sharp, projected freely downwards and backwards into the popliteal 
space, so that its extreme point was only about half an inch above the 
line of the articulation. The limb had shortened one inch, and this 
enabled us to determine accurately that the lower point or the com- 
mencement of the fracture was one inch and a half above the articula- 
tion, while the point w T here the line of fracture terminated in front was 
probably quite three inches and a half above the joint. 

The motions of the knee-joint were pretty free. The leg was ex- 
tremely wasted, and the anterior half of the foot having sloughed oft 1 , the 
sores had now completely healed over. He was able to walk tolerably 
well without either crutch or cane. 

Subsequently, Dr. G. found it necessary to sue the father of the child 
for the amount of his services, when Mr. Aiken put in a plea of mal- 
practice, and that consequently the services were without value. 

The case was tried in the March term of the Niagara circuit of 1856, 
at Lockport, N. Y., the Hon. Benjamin F. Greene presiding. 

On the part of the defence, it was claimed that the death of the foot 
was in consequence of the bandages being too tight. They failed, how- 
ever, to show that they were extraordinarily or unduly tight. While on 
the part of Dr. G., the prosecutor, it was shown that the death of the 
toes was preceded by a total loss of color, and that it was not accompa- 
nied with either venous or arterial congestion. The medical gentlemen 
examined as witnesses declared that this circumstance furnished the most 
positive evidence which could be desired that the death of the toes was 
not due to the tightness of the bandages, but that its cause must be 
looked for in an arrest of the arterial or nervous currents supplying the 
limb, or in both. They believed, also, that the projection of the superior 
fragment into the popliteal space was sufficient to cause this arrest. 
They also believed that overlapping and consequent projection could not 
have been prevented in this case, and that therefore the treatment was 
not responsible for this unfortunate result : indeed, they regarded the 
treatment as correct, and the result as a triumph of skill, in that any 
portion of the limb was saved ; the leg and foot now remaining being far 
more useful than any artificial leg and foot could be. 

The Hon. Judge, in a speech remarkable for its clearness and libe- 
rality, sought to impress upon the jury the value of the medical testi- 



486 FRACTURES OF THE FEMUR. 

mony. The jury returned a verdict for Dr. G., allowing the amount of 
his claim for services, with the costs of suit. 

Specimen 121, in Dr. March's collection at Albany, presents a similar 
disposition of the. fragments. The fracture is oblique, from above down- 
wards and backwards, and the upper portion lies behind the lower. It 
is firmly united by bone, but with an overlapping of from two and a half 
to three inches. The young gentleman who showed me the specimen 
remarked that it had been found impossible, owing to an ulcer upon the 
heel, and to other causes, to employ in the treatment any degree of 
extension. 

These two are the only examples which have come under my observa- 
tion in which a fracture at this point has taken this direction. 

Sir Astley Cooper does not seem to have recognized this form of frac- 
ture and displacement. Amesbury has, however, recorded one case, 
which came under his own observation, where, although the bloodvessels 
and nerves escaped, the bone projected through the skin in the ham, and 
finally exfoliated. 1 And he thinks the point of bone may sometimes so 
penetrate the artery and injure the nerves as to render amputation 
necessary, in order to save the life of the patient. 

M. Coural also has related a case in which an epiphysary disjunction, 
occurring in a child twelve years old, was attended with a displacement 
of the upper fragment backwards, and amputation became necessary. 2 

I know of no other cases of this rare accident which have been re- 
ported. Lonsdale refers to it as " the rarest direction for a fracture to 
take ;" and thinks that in case of its occurrence, the vessels in the pop- 
liteal space will stand a chance of being wounded ; but he mentions no 
example. The popliteal artery hugs the bone so closely at this point, 
that a displacement of the upper fragment in a direction downwards and 
backwards must always greatly endanger its integrity. Indeed, it is 
here that the artery and vein are in the closest contact with each other, 
and with the bone ; an anatomical fact which has been used by Rich- 
erand and others to explain the greater frequency of aneurisms in the 
ham. 

The prognosis in this fracture has, according to my own experience, a 
wider range then in the case of other fractures of the shaft. In a pro- 
portion of cases the union has been effected with little or no shortening ; 
a result which is not surprising when we consider that at this point the 
muscular resistance which has to be overcome is less than at any other 
point of the shaft of the femur ; and that occasionally the line of frac- 
ture is so little oblique that the fragments being once adjusted support 
themselves completely. Malgaigne says that here "oblique fractures 
are more rare" than those which are nearly transverse ; but Sir Astley 
Cooper had never met with a transverse fracture at this point, nor have 
I ; yet no doubt they do occur here more often than in other portions of 
the shaft. Malgaigne says that M. Denonvilliers thought he had found 
in the Dupuytren Museum four or five examples of exactly transverse 
fractures at this point, but he had not found one higher up. 

J Remarks on Fractures, etc., by Joseph Amesbury, vol. i. p. 293. London, 1831. 
2 Archiv. Gen. de Med., torn. ix. p. 2ti7. 



FKACTURES OF THE SHAFT AT THE CONDYLES. 487 

Malgaigne, who I infer has examined these specinens, does not seem 
to be satisfied that they represent really transverse fractures, but he does 
not speak positively upon this point. 

James A. Manly had his right thigh broken at this point when he was 
four years old, and when he was thirty years old I found it shortened 
half an inch, but the point of fracture could be distinctly felt. That it 
was not an epiphyseal fracture I was assured by the fact that the bone 
had not ceased to grow in this direction, and by observing that the frac- 
ture was too high to warrant such a supposition. 

Andrew Carr, set. 25, treated at the New York Hospital, had a short- 
ening of three-quarters of an inch. 

Mrs. Jackson, aged about thirty, had a shortening of one inch. Both 
of these latter patients were treated in the straight position, but without 
permanent extension, and therefore did not represent the best results 
which might be obtained. 

John Van Pelt, set. 51, treated by me at Bellevue Hospital in 1873, 
with plaster of Paris, and, therefore, without permanent extension, had 
a straight limb, and the shortening was half an inch. This fracture was 
caused by a fall upon his foot, and the lower end of the upper fragment 
was thrust through the flesh and skin, making a small hole in the latter ; 
but this soon closed, and the case proceeded as if it had been a simple 
fracture. 

In the following case there was no shortening, but the limb was after 
the union longer than the other : Michael Halloran, set. 40, had his left 
femur broken by a direct blow, three inches above the joint, October 6, 
1874. Having been received into my wards at Bellevue, my own ex- 
tension apparatus was applied by my house surgeon, Dr. Lewis, with 
weight and pulley, and continued seven weeks, when the fragments were 
found united ; the limb being half an inch longer than the other. This 
measurement has been repeated several times by myself and others with 
the same result. 

I have mentioned the very satisfactory result in the case of Brittin, 
with a double fracture. 

Of the following case it seems proper to say, whether the shortening 
is no greater than I have been informed or not, that the result is cer- 
tainly very favorable considering the character of the accident: — 

Col. A. Alden, of Troy, was blown up in the explosion of the maga- 
zine at Fort Fisher, Jan. 19, 1863. I saw him in consultation with Dr. 
Simmons, U. S. A., at Bedloes Island, on the eighth day after the acci- 
dent. The right thigh was broken above the condyles, the upper frag- 
ment being thrust down in front, and to the inner side. Both limbs were 
greatly bruised, swollen, and discolored. His right thigh was at this 
time shortened four inches. At my suggestion, Buck's extension was 
applied. He was never seen by me again, but his brother wrote me 
April 28, 1865, that the Colonel (then General) had returned to his com- 
mand with the limb shortened only half an inch. As I do not under- 
stand this measurement to have been made by a surgeon, it cannot be 
regarded as authoritative. 

The following two examples do not present results equal to the average 
of fractures of the shaft of the femur in other portions : — 



488 FRACTUEES OF THE FEMUR. 

W. C. Latham, get. 35, treated chiefly by plaster of Paris ; when he 
consulted me after five months the limb was shortened one inch, and the 
knee-joint almost completely anchylosed. 

Samuel Wilson, get. 47, fell from a car, striking upon his knee. He 
was placed under my care at Belle vue, and at first laid upon a double- 
inclined plane ; but this being found very uncomfortable, and not im- 
proving the position of the fragments, extension, with weight and pulley, 
was substituted. The union was effected with a shortening of one inch, 
but with very little anchylosis of the knee. 

Henry Hoff, get. 40, received a comminuted fracture of his left thigh 
four inches above the knee, from a direct blow, Dec. 2, 1879 ; fracture 
oblique. He was treated in my wards at Bellevue by extension and 
weights. It united in a straight position, but shortened one inch. 

Anna Simpson, set. 16, broke her right femur Dec. 12, 1879, by a fall 
from a rope thirty feet. Shortening at time of admission to Bellevue 
one inch and a half, showing that it was probably from a fall on the foot 
or knee. She was treated in my wards by my mode of extension. 
There is now union with less than half an inch shortening. The motions 
of the knee-joint are free. 

I have taken the pains to mention these fortunate cases more in detail 
than their simple character would seem to justify, because I wish to place 
them in contrast with the less fortunate cases. 

Mrs. Catharine Sullivan, get. 55, a large, fat woman, fell from a height, 
striking probably the right knee. The fracture was compound ; and 
when admitted to my service at Bellevue, October 9, 1866, the limb was 
greatly swollen. Immediate amputation was urged, but she refused to 
have it done. Moderate permanent extension was then employed, and 
suitable dressings applied ; suppuration occurred in the knee-joint, and 
she died in about two weeks. 

Michael O'Shea, get. 40, had his right thigh broken at the same point 
by the fall of a piece of timber upon it, and was admitted to my service, 
in the Buffalo Hospital of the Sisters of Charity, on the same day. He 
refused to submit to amputation, and he died on the tenth day, after 
gangrene had ensued. 

I was called to see a gentleman in Waverly, Tioga County, who was 
thrown from his carriage February 20, 1864, striking on both knees, 
causing a fracture of the right thigh above the condyles. On the sixth 
day, in order to establish the diagnosis, his surgeon administered chloro- 
form, and examined the knee thoroughly ; but he was seized with a 
tetanic convulsion while they were manipulating ; subsequently he had 
other similar convulsions. 1 saw him on the ninth day, when the limb 
was greatly swollen, and his general condition seemed to indicate speedy 
death. The convulsions still continued. The limb was shortened one and 
a half inches as it lay reposing upon a double-inclined plane — Daniels' 
fracture-bed. A few days later he died. 

The case of Aiken, in which the line of fracture was from above, 
down and back, already described at length, was followed by gangrene, 
and resulted in amputation. This was treated on a double-inclined 
plane. 

Daniel Welsh had his thigh broken by a direct blow just above the 



FRACTURES OF THE SHAFT AT THE CONDYLES. 489 

knee, when he was twenty years old, in Ireland. The fracture was 
compound and comminuted, and some fragments of bone subsequently 
escaped. He was examined by me five years later, when I found the 
limb shortened seven inches. My notes do not refer to the method of 
treatment. 

Wm. Hennen consulted me in February, 1854, complaining that his 
leg had been treated badly, and that he was in consequence very much 
maimed. His leg had been broken by being caught between a carriage 
and a tree. His surgeon had extension made by four strong men, and 
three long side splints were bound to the limb ; but there was no perma- 
nent extension. I found the limb shortened more than one inch and a 
half. (Both of the preceding cases were reported in the Trans, of the 
Amer. Med. Assoc, for 1857, in my paper on Deformities, etc.) 

John Bohan, get. 37, was admitted to my service, May 11, 1878, 
having fallen down an elevator and striking upon his right knee. When 
admitted the limb was greatly swollen, and the existence of a fracture 
was not recognized. Subsequently I discovered that the right thigh Avas 
broken just above the condyles, and the line of fracture was from below 
upwards, backwards, and slightly outwards. His legs were covered with 
open ulcers, and extension by adhesive strips was impossible. After 
several attempts to adjust the fragments by extension, flexion, etc., his 
limb was placed in a Hodgen's suspension splint ; but this was removed 
five days later, as it was found not to diminish the shortening, and it 
failed equally to prevent eversion of the foot. Having decided that it 
was impracticable to maintain extension, it was determined to do what 
lay in our power to prevent eversion, to which the foot and leg were 
greatly inclined on account of the riding of the upper fragment upon 
the inner side of the lower. This was accomplished very satisfactorily 
by a long side splint, well cushioned, and bound to leg, thigh, and body. 
Union was effected with a shortening of two inches and three-quarters. 

Mary Tobin, set. 50, fell seven feet, November 6, 1867, and on same 
day was admitted to Bellevue with a fracture at the base of the con- 
dyles of the right femur, in the usual direction. We found her thin, 
pale, and covered with syphilitic eruptions. 

Buck's extension was applied with eight pounds. On the 10th this 
was increased to twelve pounds. December 1st, twenty-four days after 
the injury was received, the fragments not having then united, my suc- 
cessor, Dr. Wood, took charge of the case. She was at once placed 
upon a double-inclined plane. This was continued a few days, when the 
fragments being in a worse position than before, the straight position 
was resumed. About seven weeks after the injury the fragments were 
not united, and Dr. Wood cut the quadriceps. 

February 2d, nearly three months after the accident, it was not 
united. On the 25th it was thought to be united, with a shortening of 
one and a half inches. I did not examine her at this time. 

Joshua Marquand, aet. 70, fell down a flight of stairs and received a 
fracture of the left femur, near the condyles, November 29, 1879. On 
the same day he was admitted to Bellevue. We found the limb shortened 
two inches ; and the lower end of the upper fragment had penetrated 
the quadriceps, and lay directly under the skin. An attempt was at 
ij2i 



490 FRACTURES OF THE FEMUR. 

once made to reduce the fracture by extension of the leg in the extruded 
and flexed position, but without any effect, until the patient was placed 
under the influence of ether ; when, under flexion and extension the 
sharp end of the bone w T as seen to recede a little, but it still remained 
entangled in the tendon of the quadriceps. An extension apparatus was 
now applied with twenty pounds, by which the length of the limb was 
much increased. On the tenth day Hodgen's suspension apparatus was 
substituted. 

Dec. 19, twenty days after the accident, finding no improvement in 
the condition of the fragments, and feeling assured that union would not 
take place, after consultation held with my colleagues it was decided to 
resect the projecting point of bone, and reduce the fracture. This was 
accordingly done by myself on the same day ; one inch and a half of the 
pointed extremity of the upper fragment being removed. Even then it 
was with some difficulty released from its entanglement, and restored to 
its proper position. The limb was dressed with a plaster-of-Paris splint, 
with a fenestra opposite the wound. On the following day the plaster 
splint was opened on account of the occurrence of swelling, and three 
clays later the symptoms assumed a grave aspect, gangrene having oc- 
curred over his sacrum and several other parts of his body. He died 
Dec. 25. 

It will appear, then, that while a considerable number of these frac- 
tures may be reasonably expected to reach a favorable termination, a 
much larger proportion than usual of fractures of the shaft at other 
points are to be considered as very grave accidents, and in some cases as 
demanding immediate amputation. This increased gravity is due, in 
certain examples, to the greater violence required to cause the fracture; 
in others, to the penetration of the joint by the upper fragment, and in 
all cases the hazard may be considered increased by the proximity of the 
fracture to the joint; the thinness of the soft coverings renders them 
more liable to be made compound by the penetration of the skin by the 
upper fragment ; and, finally, there exists the clanger that this fragment 
will penetrate the tendon of the quadriceps, or its tendinous expansions 
on either side, and become button-holed, thus interposing a portion of 
this dense fibrous tissue between the fragments, and preventing bony 
union, as happened in two of the cases already recorded. 

If the direction of the fracture is from before upwards and backwards, 
as happens only very rarely, there is danger of the fragments pressing upon 
the popliteal artery, vein, and nerves, and causing a secondary hemor- 
rhage, or gangrene of the leg, as happened with the boy Aikin. 

The treatment of the accident has already been discussed in connec- 
tion with fractures of the shaft in general ; and the conclusion would seem 
to be that, except in the last-named, and exceptional fracture, as a rule, 
the straight position with moderate extension affords the most comfort to 
the patient, and insures the best results. No doubt there will be cases 
in which Hodgen's swing, or some other forms of the flexed position, 
will be found the most comfortable, and give equally good results ; espe- 
cially when the parts about the knee are much swollen, or the knee-joint 
itself has been penetrated. It will be noticed, however, that in the few 



FRACTURES OF THE CONDYLES. 491 

cases in which this position was adopted by myself and others, a change 
had to be soon made. 

The most serious question is, perhaps, what shall be the course to be 
pursued when the bone becomes button-holed in the tendon, without pene- 
trating the skin. In neither of the two cases seen by me could the frag- 
ment be withdrawn from the tendon by flexion or extension, even when 
the patient was under the influence of the anaesthetic. Will it be proper, 
then, to cut through the skin, expose and remove the projecting bone, 
and then reduce it ? In one of my cases this was not done, and although 
the union was very long delayed, it is reported to have been finally 
accomplished ; but of the correctness of this report I do not feel assured. 
In the other case I resected the bone, and my patient died. I confess 
that I do not think I would be inclined to repeat the operation, but that 
I would prefer to submit my patient to the risks of non-union, or of a 
fibrous union. Upon this subject, so far as I know, surgeons have fur- 
nished hitherto no experience, and have given no opinions ; nor indeed 
am I aware that they have made any allusion to this class of cases. It 
is a matter, therefore, for future study. 

Bryant says that he has once cut the tendo-Achillis in a case of frac- 
ture at the base of the condyles, and he recommends it in all cases. 1 I 
cannot agree with Mr. Bryant as to its necessity or utility ordinarily, 
since I do not think that the lower fragment has that tendency to tilt 
backwards, which, in Mr. Bryant's opinion, renders a paralysis of the 
gastrocnemius necessary. This point has been discussed elsewhere in 
this chapter. 

It has been already mentioned that Dr. M. A. Morris, of Harvard, 
Charlestown, Mass., has repeated Mr. Bryant's operation in a case in 
which the fracture was through the base and between the condyles at the 
same time. In this case the operation proved very serviceable. 2 

§ 6. Fractures of the Condyles. 

(a) Fractures of the External Coyidyle. 

Dr. Alph B. Crosby, 3 of New Hampshire, has published an account 
of a case of simple fracture of the external condyle, in a young man 
twenty-one years of age, and which happened from a sudden twist of the 
limb, while he was undressing himself to bathe. He was " standing on a 
shelving bank, with the right leg flexed over the left in order to remove his 
pantaloons ; he lost his balance, partially twisted the leg, and fell to the 
ground." Six months after, the fragment was removed by Dr. Crosby, 
through an incision below the condyle. The recovery of the young man 
has been complete. 

The accompanying drawing represents the specimen as seen from its 
lower or cartilaginous surface, and of its actual size. (Fig. 198.) 

John O'Neill, eet. 40, fell down stairs in Dec. 1873, bending his left 
leg under his body, and fracturing the external condyle. About three 

1 Bryant, Lond. ed., An. 1872, p. 956. 

2 Morris, Med. Rec, March, 1878, from Bost. Med. and Surg. Journ., Nov. 1877. 

3 Crosby, New Hampshire Journ. of Med., 1857. 



492 



FRACTURES OF THE FEMUR 



Fig. 198. 




Dr. Crosby's specimen of 
fracture of the external con- 
dyle. 

Fig. 199. 



months later the patient was brought under my notice by Dr. Stanley. 
The patient was able to walk with a slight halt ; the fragment, appa- 
rently about one inch in diameter, moving up- 
wards about half an inch when the leg was flexed, 
with a distinct and painful crepitus. When at 
rest, the fragment formed a marked projection. 
It is not certain whether the line of fracture 
entered the joint. 

I examined the limb several times during the 
succeeding two years, and found the condition 
of matters unchanged, except that the useful- 
ness of the limb has steadily improved. Band- 
ages and knee-supports have served no useful 
purpose, and have been laid aside. 

Dr. T. S. Kirkbride has also reported an ex- 
ample of simple fracture of this condyle, which 
was produced by the kick of a horse, the blow 
having been received upon the inside of the knee. 
When this patient entered the Pennsylvania Hos- 
pital, Dec. 1834, the knee was much swollen, and 
crepitus was plainly felt, but the fragment was 
not displaced ; the muscles upon the outer side, 
however, were so strongly contracted as to ab- 
duct the leg, and produce considerable angular 
deformity. The limb could be easily made 
straight, but it returned to its former position of 
abduction as soon as it was released. When 
fully extended, slight bending of the joint did 
not give severe pain ; but when in any degree 
flexed, all motion was very painful. 

The limb was placed in a long straight frac- 
ture-box, and cold applications were made ; great 
SAvelling followed. It was kept extended in this 
manner, or in the long splint of Desault, twenty- 
eight clays ; at which time union seemed to have 
taken place, but the motions at the joint were 
very limited, and productive of great pain. 
From this period the limb was laid in a splint, 
so constructed as that the angle of the knee could 
be changed daily. At the end of about six weeks he began to walk on 
crutches, and he could then flex the leg to a right angle. 1 

Sir Astley Cooper has related a case of compound fracture of the same 
condyle, produced by falling from a curbstone upon the knees. The 
man died on the twenty-fourth day. On examination after death, the 
external condyle was found to be broken off, and also a considerable 
fragment was detached from the shaft higher up. 2 (Fig. 199.) 




Sir Astley Cooper's case of 
fracture of the external con- 
dyle. 



1 Kirkbride, Amer. Journ. Med. Sci., May, 1835, vol. xv T i. p. 32. 

2 Sir Astley Cooper, on Disloc, op. cit., p. 239. 



FRACTURES OF THE CONDYLES. 493 

(b) Fractures of the Internal Condyle. 

Dr. Thomas Wells, of Columbia, S. C, has reported an example of 
fracture of the internal condyle, accompanied with a dislocation of the 
head of the tibia outwards and backwards. The man was about forty 
years old, and intemperate. Dr. Wells was not called until two days 
after the injury was received, when he found the limb greatly swollen 
and gangrenous. The man's account of himself was that while walking 
in the back yard he fell, and thus dislocated his knee, and that he was 
then brought into the house, being unable to stand upon his feet. It 
does not appear that any attempt was made to reduce the limb, proba- 
bly because his general condition indicated that speedy death was inevit- 
able. On the fourth day he died. The autopsy disclosed, in addition 
to the dislocation of the tibia, that a thick scale of bone was broken from 
the inner part of the inner condyle, but it remained attached to the 
ligaments. 1 

A case reported to me by Dr. Lewis Riggs, a very intelligent surgeon, 
practising in Homer, Oneida Co., N. Y., was more successful. 

A lad, set. 15, was kicked by a horse, the blow being received upon the 
right knee. Dr. Riggs saw him within three hours after the accident, and 
found the internal condyle of the right femur broken off, carrying away 
more than half the articulating surface of the joint ; the tibia and fibula 
were at the same time dislocated inwards and upwards, carrying with 
them the broken condyle and the patella. The displacement upwards 
was about two inches, and the sharp point of the inner fragment had 
nearly penetrated the skin. There was no external wound. The knee 
presented a very extraordinary appearance, and the lad was suffering 
greatly. Being at a distance from town, and the Doctor having no chlo- 
roform or pulleys with him, he was obliged to depend solely upon the 
aid of five men who were present. The first attempt at reduction was 
unsuccessful ; but in the second attempt, when the men were nearly ex- 
hausted in their efforts at extension and counter-extension, and while the 
Doctor was pressing forcibly with both hands upon the two condyles, the 
bones suddenly came into position, except that the breadth of the knee 
seemed to be slightly greater than the other, a circumstance which was 
probably due to the irregularities of the broken surfaces, which pre- 
vented perfect coaptation. 

Neither splints nor bandages were required to maintain the bones in 
place ; but anticipating the probable occurrence of anchylosis, and with 
a view to making " the limb as useful as possible in this condition," he 
was placed upon " a double-inclined plane," which, being supplied with 
lateral supports, would also prevent any deflection in either direction, in 
case the limb was disposed to such displacement. 

The subsequent treatment consisted in the use of cold water dressings. 
Very little inflammation followed. A portion of the integument sloughed, 
but the bone was not exposed, and it healed rapidly. On the twenty- 
fourth day Dr. Riggs gave to the joint passive motion, and this was re- 
peated at intervals until, at the end of three months, he was able to walk 

1 Wells, Amer. Journ. Med. ScL, May, 1832, vol. x. p. 25. 



494 FRACTURES OF THE FEMUR. 

with a cane. At the end of a year Dr. Riggs examined the leg, and found 
the knee a very little larger than the other, and he could not flex it quite 
as completely. In all other respects it was perfect, and the boy himself 
declared it was as good as the other. 

Treatment of Fractures of either Condyle.— The few cases of these 
accidents which I have seen reported have been, with one or two excep- 
tions, treated in the straight position. In Kirkbride's case any degree 
of flexion was painful, although there was little or no displacement of 
the fragment ; and we think we can see, in the relative position of the 
articular surfaces of the tibia and femur, a sufficient reason why the 
straight or nearly straight position must generally be preferred. Which- 
ever condyle is broken, the remaining condyle will be sufficient to pre- 
vent a dislocation and consequent shortening of the limb, unless, indeed, 
the dislocation has already occurred as an immediate consequence of the 
injury. It is very certain that it would not take place from the action 
of the muscles when the limb was straight. In the flexed position I can 
conceive that it might take place, but yet not easily. It is not a dislo- 
cation of the limb, then, that we seek chiefly to avoid, but a deflection 
of the leg to the right or to the left, according as one or the other of the 
condyles has been broken. It will be readily seen that, in order to re- 
sist this tendency, nothing but the straight position will answer, and that 
for this purpose it will be necessary to lay a long splint upon one or both 
sides of the limb, and to secure the whole length of both thigh and leg 
to this splint. The long fracture-box used by Kirkbride, if well cush- 
ioned on all sides, seems to me at once to answer most completely this 
important indication, rendering it even unnecessary to employ a bandage, 
since the opposite sides of the box will compel the limb to adopt the 
proper position. 

As to the remainder of the treatment, it must consist essentially in the 
active employment of such means as are calculated to prevent and allay 
inflammation. 

As soon as the union is consummated the joint surfaces should be sub- 
mitted to passive motion, in order to prevent anchylosis ; and it would 
be better to commence this so early as to hazard somewhat a displace- 
ment of the fragment, rather than to wait too long. It may not, in some 
cases, be improper as early as the fourteenth day, and in nearly all cases 
it should be practised as early as the twenty-eighth. 

(c) Fractures between the Condyles and across the Base. 

Etiology. — A fracture of this character may be produced by a blow 
received upon the side of the limb or upon the lower extremity of the 
femur ; sometimes the blow has been received directly upon the patella 
when the knee was bent, and Bichat mentions a case in which it was pro- 
duced by a fall upon the feet. 

Symptoms. — This fracture is easily distinguished from the preceding 
by the much greater mobility of the fragments and by the palpable short- 
ening of the limb, since an overlapping of the broken end is here almost 
inevitable. Each fragment may be felt to move separately, and the 
motion will be accompanied with crepitus. 



FRACTURES OF THE CONDYLES. 495 

Prognosis. — The danger of violent inflammation in the joint is im- 
minent, and anchylosis of the knee is to he anticipated as the most favor- 
able result, since the joint surfaces are likely to be rendered immovable 
by fibrinous deposits in their immediate vicinity, and also by the adhe- 
sion of the muscles to one another and to the bone higher up, where the 
fracture of the shaft has occurred. More fortunate results than these 
may, indeed, be hoped for, inasmuch as they have occasionally been no- 
ticed, but they cannot fairly be expected. 

In a majority of cases such accidents have demanded, either imme 
diately or at a later period, amputation. If recovery takes place, a 
shortening of the thigh is inevitable. Mr. Canton, of London, has 
twice performed successfully resection of the joint end of the bone in 
such accidents. 1 

Treatment. — Malgaigne saw a patient who had been treated by Guer- 
bois with the aid of extension and counter-extension, who was confined 
to his bed five months, and who had at the end of eight years very little 
motion in the joint, and he seems disposed to charge in some measure 
these unfortunate consequences to the position in which the limb was 
placed, namely, the straight position. But, in my opinion, it is much 
more reasonable to suppose that, if the treatment was at all responsible 
for the results, the error consisted in too long and unnecessary confine- 
ment, and in too much extension. I suspect that the mere matter of 
position had nothing to do with the anchylosis. Malgaigne does not, 
however, himself recommend anything more than a very slight amount 
of flexion at the knee ; and to this practice I am prepared to give my 
assent ; since it will give to the limb a useful position in case anchylosis 
does occur, and it is not inconsistent with the employment of the mod- 
erate amount of extension which alone is justifiable after this accident. 
If the young surgeon should differ with me in opinion as to the neces- 
sity or propriety of using great force to retain the fragments in place 
and prevent overlapping, I beg him to consider that this fracture prob- 
ably never happens except from the application of an extraordinary force, 
and that consequently intense inflammation and swelling are almost cer- 
tain to ensue ; and that in some cases, the very fact that immediately 
after the accident, or for some hours succeeding, no swelling occurs, or 
muscular contraction, and that replacement of the fragments is easily 
accomplished, is evidence only of the great severity of the injury, and 
that the whole system is lying under the shock ; to which, if the patient 
does not succumb, sooner or later reaction will ensue, and the fragments 
will be gradually drawn up with a resistless power. The surgeon ought 
to remember also that to make extension in this case, he is obliged to 
pull upon those very ligaments and tendons about the joint which, having 
been torn or bruised, must soon become exquisitely sensitive. 

The long straight box, already recommended when speaking of frac- 
ture of one condyle, is equally applicable here ; only that it needs a foot- 
board, or some sort of foot-piece to which an extending apparatus may 
be secured, and that a pillow should be placed under the knee to give 
the limb the proper flexion/ 

1 Lancet, Aug. 28, 1858. Trans. London Path. Soc, 1860. 



496 FRACTUBES OF THE FEMUR. 

Case. — A man was admitted into St. Thomas's Hospital, London, 
Sept. 17, 1816, with a fracture between the condyles, accompanied also 
with a fracture through the shaft higher up, occasioned by being caught 
in the wheels of a carriage while in motion. There was a small wound 
opposite the point of fracture, and the external condyle was displaced 
outwards. 

The limb was laid in a fracture-box, and in a position of semiflexion. 

On the 18th of November, the external condyle, having protruded 
through the skin, and being dead, was removed with the forceps, bring- 
ing with it a portion of the articular surface. 

On the 6th of December he was discharged from the hospital, and in 
February following he was walking without any support, and with the 
free use of the joint. 1 

Case. — A gentleman living about eighty miles from town was thrown 
from his carriage, breaking the left femur just above the condyles into 
many fragments, so that when I saw him on the following day the attend- 
ing physician showed me about four or five inches of the entire thickness 
of the shaft which he had removed. The external condyle was com- 
pletely separated from the internal, and was quite movable. 

In this case the attempt to save the limb resulted in the loss of the 
patient's life on the sixth or seventh day. 

In a case of this kind Dr. Morris, of Charlestown, cut the tendo- 
Achillis with an excellent result. 2 

(d) Separation of the Lower Epiphysis. 

M. Coural relates the case of a boy 11 years old, who, while his leg 
was buried in a hole up to his knee, fell forwards, separating the lower 
epiphysis from the shaft, and at the same time driving the shaft behind 
the condyles into the popliteal space. The epiphysis also became tilted 
in such a manner that its lower extremity was directed forwards. The 
limb was amputated. 

Madame Lachapelle mentions a case in which traction at the foot of a 
child in the act of birth, caused at the same time a separation of the 
lower epiphysis of the femur and the upper epiphysis of the tibia. The 
child was born dead. 3 

Dr. Little presented to the New York Pathological Society, May 24, 
1865, a specimen obtained from his own practice. A boy, set. 11, while 
hanging on the back of a wagon, had his right leg caught between the 
spokes of the wheel while it was in rapid motion. A few hours after the 
accident, Dr. Little found the upper fragment of the femur projecting 
through an opening in the upper and outer part of the popliteal space. 
On examination, the wound did not appear to communicate with the 
knee-joint. Under the influence of an anaesthetic the fragments were 
reduced; the reduction occasioning a dull cartilaginous crepitus. There 

1 Sir A. Cooper on Disloc, etc., op. cit., p. 239. 

2 Morris, Bost. M. and S. Journ., Nov. 1877. 

3 Malgaigne, op. cit., tome i. p. 69. 



NON-UNION AND DELAYED UNION. 497 

was at the time no pulsation in the posterior tibial artery, and the limb 
was cold. The limb was laid over a double-inclined plane. The follow- 
ing day the upper fragment was again displaced, and it was found that it 
could only be kept in place by extreme flexion of the leg. This position 
was therefore adopted and maintained ; considerable traumatic fever fol- 
lowed, with swelling, and on the thirteenth day a secondary hemorrhage 
occurred from the anterior tibial artery near its origin, and it became 
necessary to amputate. The boy made a good recovery. The specimen 
showed that the line of separation had not followed the cartilage 
throughout, but had at one point traversed the bony structure. 

Dr. Voss at the same meeting remarked that he had met with the 
same accident. There was no protrusion of bone, but an abscess formed, 
and it became necessary to amputate. 

Dr. Buck saw a case which occurred in the practice of Dr. Hugh 
Walsh, of Fordham. The subject was a boy 14 years old, and it hap- 
pened in the same manner as with Dr. Little's patient. 1 

Wm. Smallwood, set. 12, Aug. 11, 1877, had his right leg caught in 
the spokes of a wagon wheel, breaking his thigh at the junction of the 
lower epiphysis with the diaphysis, the lower end of upper fragment pro- 
truding five inches through the flesh. The end was nearly square. His 
father, Dr. S. B. Smallwood, of Astoria, N. Y., the lad being under the 
influence of ether, reduced it within one hour by violent extension and 
flexion of the leg over his knee, one finger being in the wound, and 
adjusting the fragments. Lateral splints were employed. The wound 
closed in about nine months, and in the meanwhile two small fragments 
of bone escaped. He had also a sharp attack of synovitis. 

I examined him April 18, 1880, and found the leg straight, but short- 
ened three-quarters of an inch. There is complete anchylosis of the 
knee-joint, but the muscles of the leg are well developed, and he walks 
with very little limp. 

I know of no other cases of this accident. 

§ 7. Non-union and Delayed Union of Fractures of the Shaft of the 

Femur. 

Examples of delayed and of non-union of the shaft of the femur are 
not very infrequent, yet I must be permitted to say that complete failure 
to unite by bone has never occurred in my practice when I have had 
charge of the patient throughout ; and I cannot but think that in some 
of the cases which have come under my notice the mode of treatment 
was responsible for this unfortunate result. The fragments have not 
been properly supported, or there has been allowed too much freedom of 
motion. In other cases, no doubt, the cause of delay was some of those 
conditions of the patient or of the fracture which have been explained in 
the general chapter on delayed and non-union. 

The treatment of these cases demands a brief consideration, and espe- 
cially does it seem necessary to call attention to the danger of resorting 

1 Little, Voss, Buck, N. Y. Journ. Med., Nov. 1865. 



498 FRACTURES OF THE FEMUR. 

to some of those surgical expedients which may be employed with much 
hope of success, and without any danger to the life of the patient in the 
case of other long bones. 

A strong conviction has forced itself upon me that it is never proper, 
in the case of this bone, to resort to either resection and the wiring of the 
bones together, or to a seton, or to other means of establishing any consid- 
erable continuous or permanent irritation, with the view of exciting the 
tissues to the deposit of bony callus. The femur lies too deeply imbedded 
in amass of muscular and tendinous tissue to make it safe or prudent to 
excite suppurative action in the neighborhood of the bone, even if the 
drainage were the most perfect ; and both of these methods, thoroughly 
carried out, insure suppuration. To this danger these methods have to 
add the necessity, during a long period of time, of confining the patient 
in splints and in bed; while in the case of all the other long bones — even 
in the case of the leg, but especially of the upper extremities — it is pos- 
sible to permit the patient to go about, and thus to retain his general 
health — a condition most essential to the process of repair. 

In the very complete and valuable tables constructed by Dr. Frank 
Muhlenberg, compiled from various medical journals, of ununited fractures 
— published by Dr. Agnew in his Principles and Practice of Surgery — of 
155 cases of ununited fracture of the femur there were 92 cures, 3 partial 
cures, 47 failures, 12 deaths, and 1 of which the result is unknown. Of 
this number resection was practised in 32 cases ; and while 19 were said 
to have been cured, 8 died. 1 This is certainly an alarming mortality, 
but the presumption is that the proportion of fatal cases is actually very 
much larger than these tables would indicate, since fatal cases are much 
less likely to find their way into the journals than successful cases : and 
I will add that Dr. Agnew himself, a surgeon of large experience and 
acute observation, has declared without reserve that both resection and 
the seton ought to be condemned in the treatment of ununited fracture 
of the thigh. 

It has happened to me to hear of two cases of resection made by ex- 
cellent surgeons of my acquaintance. In one case the patient died, and 
in the other, although he escaped death, there was no union of the frag- 
ments. 

I have never used a seton, nor has any other surgeon within my per- 
sonal acquaintance, but its dangers are easily understood by the prac- 
tical surgeon ; and one or two cases in which other modes of operating 
have within my knowledge accidentally resulted in suppuration, will 
sufficiently illustrate the danger of inducing suppurative action in these 
tissues. 

Within a year one of the surgeons of a New York city hospital, I 
am informed, in attempting to perforate the fragments with a Brainard's 
perforator, broke the instrument. Suppuration ensued, and the patient 
died. For the following fatal result I am myself responsible : — 

Frank Pavesco, an Italian rag-picker, aged about forty years, was ad- 
mitted to Bellevue, March 18, 18T7, with a fracture of the left femur in 
the middle third, caused by a fall upon the sidewalk. I found him in 

1 Principles and Practice of Surgery, by D. Hayes Agnew, M.D., LL.D.,vol. i. p. 806. 



NON-UNION AND DELAYED UNION. 499 

my wards nearly six weeks later, when I went on duty. There was at 
that time no union of the fragments. At the end of eight weeks (May 
17) I perforated the fragments, and twisted the limb forcibly, and then 
secured the leg and thigh in plaster. On the 19th two shawl pins were 
introduced to the bone, and left in place twenty-four hours. This was 
repeated on alternate days ; but on the 23d finding that very little or no 
inflammatory action had been awakened, I penetrated the fragments with 
a gimlet, and thus fastened them together, intending to remove it in time 
to avoid all danger of suppuration. This was not clone, the gimlet re- 
maining in place several days, and until pus had formed. A counter 
opening was made, and means employed to secure complete drainage. It 
being apparent that the danger would not now be diminished by removing 
the gimlet, it was permitted to remain four weeks, during which time it 
held the fragments firmly together ; but my patient gradually sank, and 
died on the 25th of August. 

The strictly surgical expedients which are most likely to prove suc- 
cessful in cases of simply delayed union, and which sometimes have 
proved successful in cases of non-union, after the lapse of months or 
years, are violent twisting of the limb and perforation ; the perforation 
being made thoroughly through the ends of the fragments, at several 
points, and repeated from time to time, while the limb is at rest and in- 
closed in splints. 

In Muhlenberg's table of cases published by Agnew, already referred 
to, there are 17 cases treated by " manual friction," of which 7 were 
cured, 10 failed, and none died. Of 18 cases treated by " drilling with 
its modification," 9 were cured, 8 failed, and 1 died. 

In the following case I succeeded by manual frictions, drilling, 
perforation, and mechanical apparatus combined, or successively em- 
ployed : — 

Wm. F. J., set. 35, of Jetersville, Amelia Co., Va., broke his left 
thigh a little above its middle, Aug. 9, 1876, by a fall from a ladder. 
Mr. J. was a lawyer by profession, but accustomed to exercise, and in 
perfect health. He was treated with a straight splint and perineal 
band, which latter, he thinks, drew the upper fragment out of line. 

About nine months after the accident he came to New York and con- 
sulted me. I found the fragments united only by ligament; the femur 
bent outwards at the point of fracture, and shortened two and a half inches. 

May 1, 1877, my patient being anaesthetized, I perforated the frag- 
ments in various directions with Brainard's instrument, then bent the 
limb violently, and applied splints. On the 7th I opened and tightened 
the dressings. The following day I pushed an ordinary shawl pin down 
to and between the fragments, leaving it in place twenty-four hours. 
On the 10th of May I again introduced a shawl pin and left it in seven 
days, causing a slight suppuration near the skin. This was repeated on 
the 23d, and it was allowed to remain again seven days. I think this 
was repeated once or twice more. July 12th, bored through both frag- 
ments with a gimlet, and left it in forty-eight hours. Aug. 7th, I again 
used the perforator very thoroughly, and left it in forty-eight hours. 

Under my instructions, Mr. Stollman then constructed for him an 
artificial support for his thigh and leg. On the 17th of August the 



500 FRACTURES OF THE FEMUR. 

motion between the fragments was so slight that Mr. J. thought it was 
united by bone, but it was not, although the fibrous union was very close 
and firm. Having returned to his home in Virginia on the 25th of 
August, and continuing for some time to wear the apparatus, he wrote 
me, under date of November 1, 1878, that the fragments were now firmly 
united by bone — a period of six months since the treatment was com- 
menced. Several letters received since inform me that he walks long 
distances without a cane or other means of support, and that the consoli- 
dation is complete. 

In another similar case, that of Charles C. Campbell, of Alta, 111., I 
have not thus far been equally successful. Campbell, 22 years old, 
was crushed under a log, and held in this position for some time, 
Jan. 27, 1879, fracturing the right thigh in the upper part of the lower 
third. The fracture was treated with Buck's extension, but without the 
long side splint to secure quietude to the body. Extension was con- 
tinned eight weeks, when, as no union had taken place, a starch bandage 
was applied, and he was permitted to go about on crutches. About the 
15th of October the fragments were perforated, and on the 1st of No- 
vember this was repeated, with twisting of the limb ; splints were ap- 
plied, and he remained in bed ten weeks. 

When he consulted me in February, 1880, the limb was shortened 
two inches and one-quarter, and was not. united. On the 15th I placed 
him under the influence of ether, perforated the fragments very tho- 
roughly in various directions, and then wrenched the limb forcibly. 
Splints and extension were applied. The perforation was repeated 
often, as in the case of Mr. Jackson, but, at the end of eight weeks, 
there was not the slightest attempt at union. A thigh and leg support- 
was made and applied by Messrs. Teimann and S tollman, and he went 
home. 

After the first operation was made I discovered that his gums were 
spongy and ulcerated, presenting the appearance usually seen in scor- 
butus. He informed me that this condition existed before the first 
fracture occurred. 

I have twice seen the same measures fail in the hands of other sur- 
geons. 

As to the value of mechanical supports, which permit the patient to 
go about with or without crutches, there can be no doubt ; yet the re- 
ported successes of this method are not very numerous, at least in the 
case of old ununited fractures of the femur. 

Muhlenberg, in his tables, reports 29 cases treated by mechanical 
appliances alone, of which 22 were cured, 2 were relieved, 4 failed, and 
1 died. Probably some of these were recent cases. 

I have mentioned the case of Mr. Jackson, in whom I succeeded by 
mechanical appliances after operative procedures. 

Miles Farr, get. 45, had his right thigh broken by a direct blow near 
its middle, Feb. 7, 1866. It was treated in the extended position with 
Desault's apparatus, and did not unite. Dr. Thaddeus P. Seelye, of 
Chicago, operated by perforation, Sept. 29, 1867, but with no success. 
I visited him at his home in St. Lawrence Co., N. Y., Sept. 3, 1868, 
and repeated the operation by perforation, twisting and friction of the 



FRACTURES OF THE PATELLA. 501 

fragments, applying splints, etc. I left the patient in charge of a phy- 
sician living near, and do not consider myself responsible for the subse- 
quent management. No union occurred, and some time later he came to 
the city, and Dr. Hudson made for him an artificial support at my request. 
After several months there was no union, and I presume none has oc- 
curred since, but I am not able to learn the facts. 

0. S. Budlong, set. 55, of Utica, had a fracture of the left femur four 
inches above the knee, caused by a direct blow, Nov. 10, 1875. His 
surgeon is confident the bone was comminuted. Splints were applied 
after extension had been made under ether. 

I found the limb, Sept. 18, 1876, shortened two and a half inches, 
and not united. At my request, an artificial support was applied by 
Dr. Hudson, and he returned home. A letter received Oct. 3, 1877, 
says " the bone has not united, but the apparatus has been of the 
greatest comfort to him, as it enables him to walk." May 15, 1878, it 
had not yet united. 



CHAPTER XXX. 

FRACTURES OF THE PATELLA. 

Since the date of my last edition I have made a careful study of 127 
cases of fracture of the patella. Of these, 71 were either treated by me, 
or they were seen by me in consultation in the course of the treatment, 
or came subsequently under my notice. Of nearly all of these I made 
careful notes at the time. The remainder of the 127 cases (56) are 
copied from the Bellevue Hospital records, including all that had been 
recorded up to the date of the completion of the study ; excluding only 
those which had been treated by myself, and were included, therefore, 
in the class of cases first mentioned. The cases, reported at length, as 
copied from the records, have been published, with the conclusions drawn 
from them, and are now embodied in a single volume for the instruction 
of the profession. 1 

In this chapter I shall make free use of the observations and state- 
ments contained in that volume, without, however, attempting to describe 
in detail the cases, but presenting here only a summary of them. 

Total Number of Cases. — 127. 

Sex. — Males, 99; females, 28. 

Age. — Ten years and under, one case. This is the case (52) of a 
lad five years old, in whom from a direct blow, a small piece of the mar- 
gin of the patella was broken off. 

From ten years, including twenty, six cases ; of which 1 (113) was 
16 years old — a boy — the fracture being oblique and caused by a direct 
blow ; 1 (case 19) was 19 years old — the fracture was transverse, and 

1 Fracture of the Patella. A Study of 127 Cases, by Frank H. Hamilton, M.D. 
New York, Chas. L. Bermingliani & Co., Med. Publishers, 1880. 



502 FRACTURES OF THE PATELLA. 

was caused apparently by a direct blow. In this case the ligament sub- 
sequently gave way completely on the outside, and a new patella formed 
in the very much elongated ligament on the inner side. The remaining 
four cases were at the age of 20 years : all were transverse ; two are 
known to have been caused by muscular action — one by direct force, and 
in one the cause is not stated. 

Until the twentieth year of life, then, there were only three fractures, 
and these were all supposed to be caused by direct blows. Up to this 
period, muscular action seems to take little or no part in the production 
of these fractures. 

From twenty years, including thirty, 48 cases. From thirty years, 
including forty, 33 cases. From forty years, including fifty, 22 cases. 
From fifty years, including sixty, 8 cases. From sixty years, including 
seventy, 4 cases. From seventy years, including eighty, 1 case. In this 
one case, the patient, a woman, was 80 years old. 

In all the six cases included in the last two decades— that is, from sixty 
years, including eighty, four are known to have been caused by direct 
blows, and the remaining case, Bridget Callaghan, 80 years old, fell fif- 
teen feet, and it is fair to presume that the fracture was caused by a 
direct blow. 

Itw^ould seem, then, that after the sixtieth year, muscular action alone 
seldom causes these fractures. The largest number of cases having 
occurred between the twentieth and fortieth years of life. The total in 
these periods being 103, out of 122 whose ages are known; or, if we 
include the three at the twentieth year, 106 out of 122 cases. 

Right or Left Limb. — Of 134 in which this fact is recorded, ninety- 
three were in the left limb, and forty-one in the right. 

Character of the Fracture. — Of the whole number, all were simple, 
except eleven ; and of these, nine were comminuted, and two were both 
compound and comminuted. Of the comminuted fractures, cases 61 and 
94 were accompanied with fractures of the thigh also — one died of 
shock on the fourth day, and one died after amputation, rendered neces- 
sary by gangrene. 

Direction of the Fracture. — The fractures were transverse in 106 
cases — not including two which were transverse and vertical (commi- 
nuted) — of these 106 cases, twenty-two are recorded as below the mid- 
dle of the patella, sixteen at the middle, and seven above the middle. 

Cause of the Fracture. — Twenty-five are known to have been the result 
of muscular force alone ; and fifty-eight are recorded as having received 
blows upon, or, as having fallen upon the patella, and have been placed 
in the list of those caused by direct blows. In forty-three cases nothing 
is said as to the cause. 

Of the transverse fractures it will be noticed that a majority of those 
occurring below the middle are ascribed to muscular action — that is, 
twelve out of twenty in which the cause is given. Of four oblique frac- 
tures, three are known to have been from direct force ; and all of the 
comminuted fractures, except case 127, were from direct blows, as were 
also the two compound fractures. 

Active Synovitis and Bursitis. — I infer that active synovitis ensued 
in at least thirty-four cases, and probably in many others. Inflamma- 



FRACTURES OF THE PATELLA. 503 

tion of the bursa of the patella is mentioned once. Probably in most 
cases the bursa is torn open as the patella ascends, and communicates 
freely with the joint, so that bursitis could not be recognized as a distinct 
phenomenon. 

Blood in the Joint, etc. — In case 90, a compound fracture, the pres- 
ence of blood in the joint was actually demonstrated. Probably it was 
present in many other cases, but the fact could not be proven. Pretty 
extensive subcutaneous ecchymosis on the sides of the knee and in the 
ham were very frequently observed. 

Treatment. — It will be impossible to summarize the treatment. Nearly 
all of the recognized plans of treatment were adopted, but in a majority 
of cases the same plan of treatment was not continued from the begin- 
ning to the close ; and it would be difficult in most cases to say to which 
particular method the result must be ascribed. Of the specific forms of 
apparatus, there are mentioned Lausdale's, Wyeth's, Turner's, Mott's, 
Malgaigne's hooks, Sir Astley Cooper's, both of my own methods, plas- 
ter of Paris, and other forms of immovable dressings, the "lock strap," 
"wooden fingers," pulley and w T eight, crescentic pads, and figure-of-8 
bandages, also elastic bands, rollers, etc. Most of the patients have 
been kept in the recumbent posture, with the foot elevated ; but some 
have been allowed to walk about on crutches, especially when either of 
the forms of immovable apparatus have been employed. 

Results. — We now approach one of the most important parts of our 
subject, and, fortunately, the records are sufficiently accurate and full 
here to enable us to make valuable conclusions. 

It is stated distinctly in 84 cases that the union was fibrous. The 
bond of union did not permit the fragments to be moved upon each other 
soon after the treatment was concluded, and therefore may be consti- 
tuted of bone, in case 11, and I believe in three or four other cases. 

In cases 22, 23, and 64 no union ever occurred. 

The length of the bond of union is given as \ of an inch in 16 cases ; 
\ in 33 cases ; f in 13 cases ; 1 inch in 3 cases ; 1J in two cases ; 2 in 3 
cases ; 3 J in 1 case ; 4 in 1 case, and 5 in 1 case. The last four cases, 
or those in which the separation exceeds 1J inches, are respectively 
cases 22, 23, 54, and 111. 

The above records, it will be understood, do not include cases of rup- 
ture subsequent to union, but only the results of the first treatment. 
We shall refer to the results after refracture or rupture of the bond of 
union hereafter. 

It is not to be supposed that these estimates of the length of the bond 
of union are absolutely accurate. Probably the length of the ligament 
was generally a little more than is stated, but the records are sufficiently 
accurate for our purposes. All but 8 are united with a ligament of one 
inch or less in length, and the largest number have a ligament of only 
half an inch. 

Anchylosis — more or less complete — has existed in nearly all of the 
cases when the limb was first removed from the apparatus ; being most 
complete, as a rule, in those cases in which the joint has been kept the 
longest in the dressings, without the use of passive motion. 

In no case recorded has force been resorted to to overcome this an- 



504 FRACTURES OF THE PATELLA. 

chylosis ; but it has gradually disappeared under passive and active use 
of the limb within a year or two. 

Rupture of the New Ligament. — The new ligament has given way 
more or less completely in 27 cases. Possibly we may have included in 
this number one or two which were never held well in position, such as 
cases 9 and 32, in which the inner portion of the ligament alone is elon- 
gated. This unilateral elongation occurred three times on the inner 
side and once on the outer. Of the entire number, 5 were gradual, the 
elongation commencing soon after the patients began to walk ; and 18 
occurred within ten weeks after the receipt of the original injury, gen- 
erally on the seventh or eighth week, when the patient in his first at- 
tempt to walk has slipped, and the limb has been suddenly bent. After 
the eighth week there are, 4 cases at 3 months, 3 at 5 months, arid 1 at 
2 years and 4 months (case 18). Case 21 is put down as refractured 
after 4 years ; but the history of the case is doubtful. 

I think in the light of this experience it may be said that after the 
fifth month there is usually no more danger to the injured limb than to 
the sound one. 

Other Displacements of Fragments.- — The lower fragment was found 
slightly tilted forwards in case 31 ; and the lower fragment overlapped 
the upper a little in case 9. The upper fragment was tilted over by the 
elongation of the inner portion of the ligament in 3 cases ; and in the 
opposite direction by the giving away of the outer portion in 1 case. In 
case 19 a new patella was formed in the much-elongated ligament. 

Repetition of the Fracture in the Opposite Leg. — Cases 6, 45, 68, 
85, and 124 belong to this class. Perhaps also 59 ; or it may have been 
a case of refracture. These latter accidents have evidently resulted 
from the fact that the sound limb has been compelled to receive alone 
the resistance in efforts to prevent a fall. 

Hypertrophy of Fragments. — This has been especially noticed in 9 
cases ; namely, twice in the upper fragment alone, once in the lower and 
six times in both. It is probable that its occurrence is much more fre- 
quent than this record implies. 

Period of Time which elapsed before the Functions of the Limb were 
sufficiently restored to resume Labor. — Of the primary accidents, that 
is, off those in which there was no subsequent rupture of the union, I 
have been permitted to examine 23 cases, at periods of time ranging 
from four months to twenty-nine years. Only four of these are said to 
have acquired perfect, or nearly perfect, use of the limb in a less period 
than two }^ears, although in general they have resumed work within 
about one year. The cause of this inability to labor has almost invari- 
ably been the lack of the necessary freedom of motion in the knee-joint 
— a partial anchylosis. 

It is remarkable, however, that in case 23, a British soldier, there 
being no union and a separation of the fragments to the extent of 5 
inches, he w.as able to walk well at the end of 29 years, when I saw 
him. Case 22 was seen after four years with a separation of four 
inches, and case 54 was seen after seven years, and both walked badly. 

Results in Cases of Refracture or Rupture of the Bond of Union — 
27 Cases. — Of 15 cases in which the ligament gave way within a period 



FRACTURES OF THE PATELLA. 505 

of three months from the time of the original accident, that is, soon after 
the union had been effected, 12 have terminated very satisfactorily. 
Under a renewal of the treatment the fragments have united with a short 
ligament. Case 56, refractured twice, and cases 40 and 47 were not so 
fortunate. 

I do not think that in any case where the refracture occurred later 
than this was a permanent reunion effected. 



Having given this brief analysis of these cases, we shall proceed to 
consider the subject of fractures of the patella in a more general way. 

Etiology of Fractures of the Patella. — Twenty-five of the cases re- 
ported by me are known to have been the result of muscular force alone ; 
the fractures having occurred without a fall or w T hile the patient was 
standing, and in some" cases when the knee was not bent, the fracture 
being announced by a distinctly felt snap. I believe, however, that 
muscular action was more or less efficient in causing the fracture, in all 
the simple transverse fractures, and in at least one of the comminuted 
fractures ; that is to say, in 107 of the 127 cases. 

My reasons for this opinion are : the great power of those four strong 
muscles which unite to form the tendon of the quadriceps — the fact that 
ninety-nine occurred in males — that only three occurred in persons 
under twenty' years of age, and only five after the sixtieth year — the 
largest number being between the twentieth and thirtieth years of life — ■ 
the remarkable uniformity in the direction of the fracture ; and finally 
because I am unable to cause a transverse fracture on the cadaver by a 
direct blow. I might have added also the fact, as attested by museum 
specimens, that the fracture is very uniformly from before backwards 
and downwards, as would be the case if it were caused by a cross- 
strain, the active force being attached to the upper fragment. That the 
bone breaks most often in the lower third, may perhaps be explained by 
some mechanical law, but I am not prepared to explain it. 

A patella having given way transversely to muscular action, those 
fibres of the quadriceps which are inserted into the sides of the patella 
still continuing to act, may break the bone vertically, or cause them to 
separate laterally. No doubt this is what happened in case 127. 

The source of error in estimating the value of muscular action in the 
production of this fracture has been, that in the majority of cases the 
patients have actually fallen upon their knees, and all such cases have 
been set down as caused by direct force ; but in a fall on the knee upon 
a plane surface, when the leg is flexed to a right angle with the body, 
the pattella does not touch the plane ; it is only the tuberosity of the tibia 
which touches, and the contact with the plane has had nothing to do with 
the fracture, except as causing, by the concussion, a more active con- 
traction of the muscles already rendered tense by the position and by 
the effort to prevent the fall. If a man falls headlong, with his knee 
slightly bent, the patella' may strike the floor, and in this way, and by 
other methods, the patella may receive a direct blow ; but even then, if 
the fracture is transverse, it is probable that the blow induced the frac- 
ture by causing a sudden spasmodic action of the muscles, for as I have 
33 



506 



FRACTURES OF THE PATELLA. 



said before, we cannot imitate the fracture by a direct blow on the 
patella of the cadaver. 

Agnew, Malgaigne, and others have observed the frequency with which 
this cause has operated in the production of transverse fractures of the 
patella. Agnew speaks of it as being frequently produced by the act of 



mounting a horse, 



Fig. 200. 





Simple transverse fracture. 



Comminuted fracture. 



Fig. 202. 




Anatomy, Pathology, and Semeiology. — I have already stated that 
the fracture is almost uniformly transverse, occasionally oblique, and in 

a few cases the line of fracture is slightly 
curved ; very seldom is the line of fracture 
vertical. The fracture occurs most often in 
the lower third, and least often in the upper 
third. In the transverse fractures the di- 
rection of the fracture is from before back- 
wards and downwards. 

In a large majority of cases the lesion is 
limited to the bone, its periosteal coverings, 
including the synovial membrane, and the 
thin and scattered fibres of the tendon of the 
quadriceps, which traverse the front of the 
bone to become continuous with the liga- 
mentum patellae. Perhaps a few of the 
fibres of the aponeurosis on either side of 
the patella give way also, but the lesion of 
this aponeurosis is ordinarily not extensive. 
For this reason the upper fragment seldom 
separates from the lower more than one 
inch, and in most cases only about half an 
inch. It is only when great and extraordi- 
nary muscular force has caused the fracture 
that the aponeurosis is sufficiently torn to 
permit the upper fragment to ascend two 
inches or more, and Ave may always estimate 
the extent of this latter lesion by the extent 
to which the upper fragment is drawn up. 
This was sufficiently illustrated in a dissec- 
tion which my Senior Assistant House Surgeon, Dr. Girdner, kindly 
prepared for me. He exposed the patella and the quadriceps with its 
broad lateral aponeurosis, which passes down, spreading out, to be in- 
serted finally into the sides of the tibia and fibula at their upper ex- 




Transverse fracture of the patella. 



FRACTURES OF THE PATELLA 



507 



tremities. He then divided the patella transversely with a chisel, 
leaving the aponeurosis untouched, and we observed now that by no 
amount of pressure upwards short of that which would cause a laceration 
of the aponeurosis, could the upper fragment be made to ascend more 
than half or three-quarters of an inch. By cutting the aponeurosis on 
either side, the fragment could be pushed up further, but the cutting 
had to be very extensive before it could be pushed up three inches, as 
has happened in some of the recent cases which have come under my 
observation. Such extensive separation, therefore, implies necessarily 
extensive laceration of the aponeurosis. 



Fig. 203. 



Fig. 204. 





Separation of the fragments in moderate 
flexion when the whole aponeurosis and 
tendon is torn. 



Fragments separated by forced flexion 
of the knee. 



There is another anatomical lesion, the existence of which it may be 
proper to assume in the majority of cases, although we have not the 
means of demonstrating its occurrence. The posterior wall of the bursa 
in front of the knee is probably lacerated, and the joint surfaces, or 
articular synovial capsule is made to communicate freely with the cavity 
of the bursa. 

This bursa is usually present in adult life, and is especially well de- 
veloped in males. Its posterior wall is composed of a thin synovial mem- 
brane, which is in direct contact with the front of the patella and its 
immediate investments ; so that a separation of the fragments to the 
extent of half an inch could scarcely occur without laying open the bursa. 
The exception must be found in those cases in which the bursa is not at 
all, or is only imperfectly developed, or the fracture has taken place at a 
point which does not exactly correspond to the under surface of the bursa. 

I have once or twice observed, a few days after the fracture, a fulness 
in front of the patella so defined as to seem to indicate that the bursa 
had not been torn, but that it had inflamed and become filled with serum; 
but I imagine that this appearance might be presented sometimes when 
a communication with the joint had been established, and the bursa had 
become filled, its anterior wall being simply pressed forwards by the fluids 
of the joint. 



508 FRACTURES OF THE PATELLA. 

There remains then, usually, in front of the joint nothing but the skin 
and a thin layer of areolar tissue, or probably the skin alone, which if 
it were not at this point very redundant and elastic would often be torn, 
rendering the fracture compound. In no case has the skin been torn 
under my notice as an original accident, however much the fragments 
may have separated; but in one case, not recorded in the preceding re- 
port, but which was at the time under the care of Dr. Erskine Mason, 
the skin was torn in a subsequent accident — a rupture of the new liga- 
ment — the fragments being separated very widely. Suppuration of the 
joint ensued, and it became necessary to amputate at the knee-joint by 
Cardan's method. After which he made a good recovery. 

It has been found possible sometimes for the patient, immediately after 
the accident, to continue standing, or even to walk by exercising great 
care, but in most cases the patients have at once fallen to the ground and 
were unable to rise. 

Very speedily, often within a few minutes after the injury is received, 
the joint appears swollen. This early swelling must be in part attributed 
to the effusion of blood into the joint from the broken patella and adja- 
cent tissues. The presence of blood in the joint was demonstrated in 
case 90, and there can be no reason to doubt that it is often, perhaps 
always, present in the joint in some amount, after the fracture, where it 
probably undergoes a pretty rapid disintegration and is mostly absorbed. 

There is quite often, also, at an early date, considerable discoloration 
of the skin on the sides and back of the knee, caused by the infiltration 
of the blood into the subcutaneous areolar tissues. 

A synovitis and bursitis (when the bursa is torn) are inevitable also ; 
the amount of inflammation being more or less in different cases, but 
being, in most cases sufficient to fill the joint with serum and probably 
some lymph, within the space of a few hours, or days at most. This 
effusion, caused by the synovial inflammation, generally begins to disap- 
pear within a week or ten days, and cannot usually be detected after the 
second week ; but meanwhile, pretty often, a more or less extensive cel- 
lulitis ensues, involving the front and sides of the knee and extending 
some distance up and down the limb. Usually this is moderate, but it 
has occasionally, and especially when injudicious pressure has been em- 
ployed, resulted in suppuration of the areolar tissue. 

Mode of Union and Prognosis. — The frequency with which, accord- 
ing to my observations, the bond of union has given way at some subse- 
quent period, renders it necessary that I should speak of the character 
of the union and the prognosis relating to primary accidents, and the 
character of the union and the prognosis relating to secondary accidents, 
separately. 

Character of the Union and Prognosis in Primary Accidents. — In 
my published cases the bond of union is known to have been fibrous in 
84, and in no case is it known to have been bony : but quite often it has 
been thought, when the patient was first dismissed, that the union was 
bony, and in almost every case a much later examination has shown that 
it was fibrous. When the dressings are first removed there is often such 
a degree of hardness of the tissues between the fragments as to lead one 
to suppose that the fragments have united by bone, and they are so fixed 



FRACTURES OF THE PATELLA. 509 

that they cannot be made to move separately, but which deceptive ap- 
pearance is removed in the course of a few weeks or months. I do not 
know positively that in any case the union was by bone. If I were to 
state my convictions I would say, that probably none of the transverse 
fractures were united by bone ; and that only a small proportion of the 
vertical and comminuted fractures were thus united. I do not deny the 
possibility of union by bone. A few apparently authentic cases, verified 
by the autopsy, have been reported from time to time, but I have never 
seen such a case. 

The length of the bond, in primary cases, is usually about half an inch, 
and ranges from one-quarter of an inch to five inches : but of the whole 
number recorded by me, there are only four in which the new ligament is 
more than one and a half inches in length. These latter are, therefore, 
exceptional cases ; and were rendered so by the greater violence inflicted, 
and the more extensive rupture of the aponeurosis and muscle, or by in- 
judicious treatment. 

I will relate the cases in order that we may appreciate ivhere the respon- 
sibility generally lies, when fragments unite with so much separation : — 

I found Samuel Hanna, aet. 38, in my ward at Bellevue, June 1, 1875, 
admitted an account of an abscess which had formed without any appre- 
ciable cause in the areolar tissue, just above the left knee. He had an 
old fracture of the patella in the same limb, the fragments being sepa- 
rated nearly four inches. He w T as unable to extend the limb by muscular 
action, there being apparently no bond of union between the fragments. 

He gave the following account of the injury: The accident occurred 
in December, 1871, about three years and five months before. He was 
immediately taken to Bellevue Hospital. On the fourth day the limb 
was laid upon an inclined plane. On about the seventh day a plaster-of- 
Paris splint was applied, from the foot to the hip. He was permitted 
to go about on crutches. When the splint was removed the fragments 
were separated two inches. He has had no treatment for the fracture 
since. 

John Sharkie, aet. 24, a soldier in the British service. Was struck in 
the right knee while he was sitting with his leg bent under him. 

He was immediately put under charge of the surgeon of the 89th regi- 
ment of infantry. Severe inflammation and swelling ensued, and no 
apparatus was employed until the twelfth day, a compress was then laid 
over both fragments, and they were bound on with a roller, the limb being 
laid upon an inclined plane. The bandages were removed at the end of 
four months, when the upper fragment at once drew up toward the body. 
It was eighteen months before he could walk without a cane. This is 
the account given to me by himself. 

Twenty-nine years after the accident, March 27, 1855, I found when 
the limb w T as straight, that the upper fragment lay two and a half inches 
above the lower, and when the limb w T as flexed it separated five inches. 
No trace of a ligament or other bond of union could be felt. He walked 
well, without a cane, there being very little or no halt, but he could not 
walk fast. 

Jeremiah Murphy, of No. 3 Bridge Street, New York, aet. 56, broke 
his left patella transversely, below the middle, by a fall upon the knee. 



510 FRACTURES OF THE PATELLA. 

A surgeon was called, and applied bandages. He was four or five 
weeks in bed, and then went out, using a cane. The fragments were then 
found to be much separated. Aug. 80, 1879, seventeen years after the 
accident, I found the fragments separated 3J inches when the leg was 
straight, and 4f when it was flexed. Fragments of normal size. No liga- 
ment between the fragments ; but along their outer and inner margins 
the tendinous fibres of the quadriceps are prominent, and especially on 
the outer side. He cannot extend the leg by muscular action when sit- 
ting, but he can flex it to an acute angle with the thigh. Standing, he 
can flex and extend it perfectly. In extending he turns the foot out, in 
order to bring into action the outer portion of the quadriceps. He has 
always, since this accident, been somewhat lame, but could walk several 
miles and carry loads without a cane. 

May 25, 1879, he slipped and fell, striking upon the right knee, and 
breaking the right patella transversely about its middle. June 1, a sur- 
geon applied adhesive strips over and above the patella, then a plaster- 
of -Paris bandage from the hollow of the foot to above the knee. Frag- 
ments were separated an inch or more. Began to walk. A few days 
later the leg suddenly gave way, and he fell back. The skin became 
discolored, and it swelled very much. 

When he consulted me the fragments of the right patella were separated 
If inches, when the limb was straight, and three inches when it was 
flexed. He walked slowly without a cane, but was in constant fear of 
falling. I advised him to submit to a second trial to obtain a more satis- 
factory result in the case of the right leg, but he declined to do so. 

Peter Waters, get. 23, mason, 1830 Third Ave., while running caught 
his heel, and in his effort to save himself fell back. At this moment he 
heard his patella crack, and found at once that he could not stand. 

On the following day, April 30, 1874, he was admitted to Bellevue. 
The fracture was found to be transverse below the middle, and the frag- 
ments separated three-quarters of an inch. Evaporating lotions were 
applied. 

May 5. A silicate- of -lime splint was applied, the fragments having 
been previously approximated by adhesive strips locked over the front 
of the patella. 

loth. Splint removed, as it did not have sufficient firmness, and 
plaster -of -Paris splint substituted, which was soon cut open. 

16th. Seventeenth day. Discharged at his own request, with in- 
structions to report from time to time. (No farther record.) 

I saw and examined this man Oct. 22, 1879, more than five years 
after the accident. The fragments were separated two inches, and 
united by a firm ligament. No hypertrophy of fragments. He can 
use the leg almost as well as the other — can flex and extend fully, and 
run up and down stairs. 

When he left the hospital, with the plaster splint on, he wore it about 
two weeks; the joint was then very stiff. On taking off the splint he 
moulded a piece of sole-leather and made for himself a knee-cap, which 
he wore a few weeks longer. Gradually the anchylosis disappeared, 
and in about one year he resumed work as a mason. 

I have found the fragments tilted, in consequence of a yielding of the 



FRACTURES OF THE PATELLA. 511 

new ligament, or because of a pressure of the bandages, in four cases. 
In three of these it was the inner portion of the ligament which had 
given way, and in one the outer. If from so few examples it is proper 
to infer the existence of a rule, a'nd to declare that the inner portion 
gives way most often, we may perhaps find a reason for the rule in the 
fact that the inner portion of the quadriceps is more powerful than the 
outer portion, and might therefore act more energetically upon the inner 
margin of the upper fragment, and cause it to separate more widely from 
the lower. 

Malgaigne made the same observation which I have made, and does 
not hesitate to speak of it as a rule, or absolute law ; declaring that it 
is always the inner portion which is found elongated ; but I have men- 
tioned one example in which the fact was otherwise. Boyer also alludes 
to the tendency in the upper fragment to tilt outwards ; and both of 
these writers think that the phenomenon is due to the manner in which 
the pressure of the apparel was made to bear upon the upper end of the 
upper fragment. The upper margin of this fragment is not horizontal, 
but oblique, its outer portion being considerably above the plane of its 
inner portion; so that any form of adjustment in which the plane of 
pressure from above is horizontal, will press more effectively upon the 
outer than upon the inner portion, and cause the upper fragment to tilt, 
or incline outwards. It seems to me that both unequal muscular action 
and the direct but unequal, or maladjusted mechanical pressure of nearly 
all forms of apparel employed to bring down the upper fragment, may 
be considered as alike responsible for this result. This, as will here- 
after be seen, I have sought to avoid by employing a somewhat elastic 
cotton roller for the purpose of making the downward pressure. 

Occasionally it is found, when the fragments have united, that one or 
both of the fragments are inclined a little forivarcls at the point of 
fracture, forming an angle salient in front. Usually it is but one of the 
fragments that is thus inclined ; and in most cases, if not in all, that 
fragment which is the longest is the one which projects. Thus, of my 
published cases, 9 and 31 were transverse and in the upper third, and 
when union was completed the upper margin of the lower fragments 
overhung the lower margins of the upper. 

The longest fragment resting upon a convex surface, and being no 
longer held in position by a counter force, the ligamentum patellae or the 
quadriceps, must inevitably incline forwards. Indeed, I have seen this 
condition present in a recent fracture before any apparatus had been 
applied ; but in such cases very slight pressure, applied from before 
backwards, was sufficient to restore it to place ; and it is quite certain 
that for this result after union is consummated, the apparatus employed 
to bring the fragments together is mainly responsible. Both the quad- 
riceps and the ligamentum patellae have their insertions nearer the ante- 
rior than the posterior margins of the patella, a thin layer of tendinous 
fasciculi actually traversing its anterior face. The upper and lower 
margins of the patella, therefore, present no elevations for the applica- 
tion of concentric pressure ; and if by any form of apparatus, except 
Malgaine's hooks, concentric pressure is made, it must be accomplished 
by causing a depression in these firm ligamentous bands, or a recession 



512 FRACTURES OF THE PATELLA. 

from the tegumentary surface, in order that the concentric forces may 
have a point oVappui. This pressure must depress the corresponding 
margins of the two patellar fragments, and elevate their broken margins ; 
and in this case the longest fragment will suifer the greatest displace- 
ment. To a certain degree this must occur even with Malgaigne's hooks, 
as we shall easily see when we consider their mode of application as re- 
commended by himself ; but in a much less degree than by any of the 
usual modes of treatment ; such, for example, as those in which two hard 
crescents or a padded ring are employed to bring the fragments together. 
No doubt it is occasioned also sometimes by the pads which some sur- 
geons place in front of the patella, and which get displaced and press 
unequally. 

Both these displacements, namely, the tilting and the forward pro- 
jection, are imperfections which contribute their proportion to the subse- 
quent maiming ; causing in the one case a relative loss of strength in the 
ligament, and in both cases causing some irregularity in the movements 
of the patella over the surface of the femur. 

There is another form of displacement to which I have not yet re- 
ferred, but which seems in most cases to be temporary, although it is 
probable that it is not in all cases, namely, a simple lateral displacement. 
This existed in case 9, before the treatment was fully terminated. The 
upper fragment was found displaced inwards one-quarter of an inch, and 
it could not be moved from this position — at least not without greater 
force than it seemed proper to apply. In this case, however, the frag- 
ment subsequently, when he had used the limb some time, gradually 
loosened and resumed its natural position. I think the same happened 
in one or two other cases, and that they subsequently came into line. 
Probably in each case it was caused by the lateral pressure of the 
bandage or of other parts of the dressing, and might, therefore, have 
been avoided. 

It is easy to imagine that if the fragments are thus displaced the bond 
of union may be imperfect or unequal on the two sides, or that it might 
diminish the chances of union, and in either case the evil results might 
be permanent and serious. 

Hypertrophy of the fragments. This must be distinguished from an 
exostosis, such as is frequently observed along the margins of the frac- 
ture, and which is never considerable, only causing a slight irregularity 
in the surface of the bone, but which may be present without any peri- 
pheral enlargement or expansion of the fragments. 

This actual hypertrophy has been observed by me in nine cases, 
namely, twice in the upper fragment alone, once in the lower fragment 
alone, and six times in both. The occasional hypertrophy of the frag- 
ments has been noticed by other writers, and Malgaigne has furnished 
two illustrations. The same thing is known to happen pretty often in 
some of the long bones when broken near their extremities where the 
structure is cancellated. I have noticed it often in the fracture of the 
humerus near its lower end, the lower fragments being in all such cases 
the ones which become hypertrophied. In the case of the humerus the 
hypertrophied fragment, sometimes after many months or years, is found 
to diminish ; but whether such a gradual diminution in size takes place in 



FRACTURES OF THE PATELLA. 513 

examples of hypertrophied patellae I am not certain. It has not seemed 
to me that it does occur. 

Period required for Recovery of the Perfect Use of the Limb. — I will 
quote what Malgaigne says upon this subject: " Camper has stated that 
in one or two years the power is recovered, whatever may have been the 
interval between the fragments. An evident exaggeration, since he him- 
self speaks of a lady with a separation amounting to three fingers' breadth, 
who still limped four years after the receipt of the injury. Mr. Benja- 
min Bell makes one inch the limit of separation, allowing for the resto- 
ration of the firmness of the knee ; Boyer follows him ; M. Velpeau, on 
the contrary, affirms that he has seen the functions of that joint com- 
pletely re-established, with an interval of two or three inches between 
the fragments. Such assertions are, in my opinion, only accounted for 
by some inaccuracy of examination, and for my own part I have never 
seen the functions of the limb completely restored, even when the sepa- 
ration was limited to one-third of an inch." 1 For myself I have seen 
three or four perfect results, so far as the use of the limb is concerned. 
For example, in case 31, after nineteen years when I examined the patient 
carefully, there was not the slightest difference in the freedom of use of 
the two limbs ; yet the union is by a ligament of three-quarters of an inch 
in length. 

The fact seems to be, that more or less loss of freedom in the motions 
of the joint and of strength and stability in the limb, remains in the 
majority of cases for a long period of time, and often during life ; but 
that in a few exceptional cases, where the separation does not exceed 
one inch, the functions of the limb are completely restored within one or 
two years. It is remarkable, also, how well the functions are restored, 
after a long time, in some cases when the separation is very great, as, 
for example, in case 23, in which the separation was five inches when 
the knee was flexed, without bond of union of any kind ; yet when I 
examined him at the end of 29 years he walked well without a cane, and 
with very little or no halt, but he could not walk fast. 

The first and main impediment in the restoration, of the functions of 
the joint is the anchylosis, which is in many cases at first nearly com- 
plete. This anchylosis being due to the passive contraction of the artic- 
ular ligaments, as a consequence of long disuse ; to adhesions and inflam- 
matory infiltrations among the torn muscular and tendinous fibres, and 
between these latter and the upper fragment of the patella as it lies more 
or less buried in the torn tendinous tissues. It is never safe to attempt 
to overcome this anchylosis by force, consequently the process of resto- 
ration must be slow and uncertain, and it will generally be found to be 
many years before the leg can be flexed upon the thigh to the same angle 
as in the case of the opposite limb. 

In a certain degree, also, the changed relations of the fragments to the 
articular surface of the femur may be responsible for the lameness. 

As to what influence the nature and length of the new bond of union 
has upon the usefulness of the limb, I am prepared to say, first, that the 
fact that it is generally fibrous and not bony is probably of no conse- 

1 Malgaigne, op. uit., p. 606. 



514 FRACTURES OF THE PATELLA. 

quence, provided the bond of union does not exceed one inch in length. 
It certainly is in no way responsible for the anchylosis ; and, as to its 
effect upon the stability or strength of the limb, there is no reason to 
suppose that this slight diminution in the range of the contraction and 
elongation of the quadriceps will have, after one or two years of use, any 
appreciable effect upon the stability of the limb. Indeed, so far as I 
have been able to ascertain, in all of these cases the patients have been 
able, after a time, to extend the limbs as completely and as forcibly as 
before. 

If, however, the length of the fibrous bond is much more than one inch 
there is generally an appreciable loss of the power of complete and fixed 
extension. 

We have had recorded too few well-attested examples of bony union 
to enable us to declare whether the fibrous union or the bony union is 
most liable to a secondary accident — a refracture. It would seem rea- 
sonable to suppose that the newly-formed bone would be thinner than 
the original bone and less spongy, and that in consequence of its com- 
pactness and thinness it would break more easily under a cross strain 
than would an equally thick, but flexible, ligament. It is well known 
that a rupture of the ligamentum patellae, or of the united tendon of the 
quadriceps occurs much less often than a fracture of the patella. 

My conviction, therefore, is that a fibrous union of less than one inch 
in length is quite as advantageous as a bony union, but I do not state 
this as an established fact — a conviction which is enforced by a case 
which Dr. James L. Little, of this city, lately brought to my notice. 
John Mullen, set. 22, broke his left patella transversely below its middle 
in March, 1879. It united by fibrous tissue with a separation of half an 
inch. About five and a half months later he slipped in walking, and the 
same patella was found to be fractured at a point about half an inch 
above the first fracture and transversely. This had united also by fibrous 
tissue of the same length as the first. I saw him soon after he left St. 
Luke's Hospital, where he had been treated by Dr. Little. The three 
fragments are movable upon each other, and no doubt can exist as to the 
character of the accident. In this case at least, then, after the lapse of 
a little more than five months, the new ligament has proven itself to be 
stronger than the original bone. 

Rupture of the Newly-formed Ligament^ or Refracture. — In the prog- 
nosis of original fractures we have to include the danger of a refracture. 
Indeed, my statistics, already referred to, show a startling frequency of 
this accident. It is known to have occurred in twenty-five cases, and in 
two additional cases the ligament has given way partially. Some of 
these cases were persons who sought my advice, and they might not 
therefore correctly represent the true proportion in a given number of 
consecutive cases, and not one of them were cases which had throughout 
been under my own care ; but, on the other hand, it will be remembered 
that a considerable number of the one hundred and twenty-seven cases 
were not seen or heard from by me, after the treatment was terminated ; 
so that, on the whole, I think that twenty-seven out of every one 
hundred and twenty - seven represents the average ratio of these 
accidents. 



FRACTURES OF THE PATELLA. 515 

A knowledge of this fact, which now for the first time has been re- 
vealed to me, is of the greatest importance, as indicating the necessity 
for great care in the use of the limb after the surgeon has practically 
dismissed the patient ; but it is reassuring to know that two-thirds of the 
whole number were ruptured very soon after leaving off the apparatus ; 
that is, within ten weeks after the original fracture had taken place : and 
that five of these took place gradually, commencing when the patient 
began to walk. Only two occurred later than five months after the 
injury, or about three months after the apparatus was removed. It would 
seem, therefore, that it is only necessary to provide against the accident 
during the first three months after removal of the splint, and that after 
this a rupture is no more likely to take place than if it had not been 
broken. 

Fracture of the Opposite Patella. — -This has happened five times in 
the one hundred and twenty-seven cases, and was no doubt due in each 
case to the greater effort made by the quadriceps of the sound limb to 
sustain the body, when the equilibrium of the body had been disturbed. 

Character of the Union and Prognosis in the Secondary Accident. 
— A majority of these cases refuse to unite again, even by fibrous tis- 
sue, whatever means may be employed ; and the few cases of success 
which have come to my knowledge are confined almost entirely to those 
examples in w T hich the rupture took place very soon after the apparatus 
was removed, and in which the limb was immediately subjected to treat- 
ment. 

When the fragments do not unite the patients are for a long time 
seriously maimed, the limb lacking stability, and often giving way sud- 
denly under the weight of the body. In most of these cases, however, 
a judicious treatment, such as I shall hereafter indicate, will eventually 
give considerable stability to the limb, and enable the patient to walk 
with much safety and ease. 

Treatment, in Primary Accidents. — Our investigations have brought 
us to conclude that in a large majority of cases, under any plan of treat- 
ment, a fibrous union of the fragments is all that can be expected ; and 
that probably a fibrous union, w T ith only a separation of a half or three- 
quarters of an inch, is as useful as a bony union. 

The only methods which could encourage a reasonable hope of pro- 
curing a bony union, are Malgaigne's hooks, and wiring the fragments 
together. 

Malgaigne's hooks have hitherto not been proven to have accomplished 
this result, not even in the hands of the distinguished inventor. In fact, 
contrary to what I would have expected, there has been among the cases 
reported as many examples of fully recognized fibrous union, as have 
occurred where some other plans of treatment have been followed ; the 
fibrous band has been no shorter, and the number of cases in w T hich a 
bony union has been supposed to exist soon after the removal of the 
apparatus, is no greater than my own dressings and experience have 
supplied. 

On the other hand, several cases have been reported of dangerous or 
disastrous inflammation induced by the hooks, and to this objection many 




516 FRACTURES OF THE PATELLA. 

other methods are never liable. There seems no possible reason, there 
fore, why in any ordinary, simple transverse fracture, in which the original 

separation does not exceed one 
■ inch or even one and a half 

inches, this method should be 
employed ; but in cases in 
which the original separation 
exceeds this, and especially in 
cases of a refracture or rupture 
of the fibrous bond, accompa- 
nied with great separation, it 
is my opinion that Malgaigne's 
Maigaigne's hooks. hooks are entitled to a farther 

trial. 
As to the method practised by Dr. J. E. Van der Meulin, of the Uni- 
versity of Utrecht, in July, 1878, and later by Cameron, of Glasgow, 
Mr. Rose, of London, 1 and one or two others, of cutting into the joint and 
wiring the fragments together, under carbolic-acid spray, I feel bound to 
say, that, as applied to a primary accident, it is offering a very grave 
and dangerous substitute for other perfectly safe, and so far as is yet 
proven, equally efficient methods ; it is hazarding the life of the patient 
without offering any equivalent. Of the two cases reported by Mr. 
Rose — one of which he pronounced a bony union, but presented no satis- 
factory evidence that it was such — Mr. Bryant, who was present, said: 
" The result in this man's case was very good ; that in the woman's case 
was not so good as he had often seen on the ordinary plan." 2 The sur- 
geon who undertakes such an operation is, in my opinion, more courage- 
ous than wise, and so I think Mr. Lister and Mr. Bryant ought to have 
said. I think, also, it is too dangerous, and too liable to fail, to entitle 
it to a trial in secondary accidents. 

Dr. Byrd, of Quincy, 111., says that he had as early as May, 1876, in 
the New York Medical Journal, called attention to the fact that Dr. 
George McClelland, of Philadelphia, had made the same operation, only 
without the carbolic spray, many years ago ; but I do not think we need to 
feel ambitious to establish for ourselves a priority of claim in this matter. 
Cutting the quadriceps, a method said to have been adopted by Mr. 
Gould, 3 demands a very extensive subcutaneous incision, as any one will 
easily convince himself by looking at this muscle, with its broad and 
strong tendinous insertion into the top and sides of the patella ; and I 
venture to say that no surgeon has divided all of its fibres, or even the 
fibres of the rectus, in his subcutaneous incision, and certainly not 
without carrying his incision freely into the upper part of the joint. 

The method employed by Oilier, Goujon, and Wyeth (example 47 of 
my published cases), of injecting between the fragments fresh marrow 
cells, has as yet yielded no results. Nor do I think it is likely to suc- 
ceed for many reasons, and especially because the u germs" cannot be 

1 New York Med. Journ., May, 1876, p. 463 ; Med. Record, April 3, 1880, p, 384. 

2 Rose, Am, Journ. Med. Sci.^ January, 1880, p. 278, from Lancet, Nov. 22, 1879. 

3 Gould, debate on Mr. Rose's Case, op. cit., p. 279. 



FRACTURES OF THE PATELLA. 517' 

placed actually between the fragments without being in the cavity of the 
joint, where of course they could serve no purpose. To place them in 
the thin tegumentary covering, which alone remains, when the separation 
exceeds half an inch, would be, I think, equally useless. It possesses, 
however, this advantage over the wire, namely, that it is harmless. 

In order to accomplish the best results, with the least possible danger 
to the life or limb, that is, to produce the shortest ligament, and possibly 
to bring about bony union, while the complete integrity of the joint is pre- 
served, there are presented four simple indications of treatment, namely: — 

First. Approximation of the lower fragment to the upper by straight- 
ening — extending — the leg upon the thigh. 

Second. Securing immobility of the knee-joint by a splint. 

Third. Relaxation of 'the quadriceps muscle. This indication is ac- 
complished in a small degree by flexing the thigh upon the body ; but 
the effect of this posture is not so great as some writers have supposed. 
The quadriceps has but one origin from the pelvic bones, and conse- 
quently flexion of the thigh does not very greatly relax its muscular 
fibres. Yet that it possesses some value in this direction is easily de- 
monstrated by experiment. The quadriceps is chiefly relaxed by ex- 
tending the leg upon the thigh, that is, by placing the limb in a straight 
position and maintaining it in this position. 

The fourth indication is to approximate the fragments by direct pres- 
sure. Without this pressure the relaxation of the muscle will not bring 
the fragments into juxtaposition, or even make them approximate this 
desirable condition. 

In order to make direct pressure, surgeons have devised a great variety 
of methods ; most of which are liable to the serious objection that they 
press too tightly upon the entire circumference of the limb to render 
them perfectly safe under all circumstances ; and especially when the 
opposing forces, which are intended to approximate the fragments, are 
applied with the view of securing absolute coaptation, as many of the in- 
ventors declare to be their intention. That danger exists from this source, 
the following case will illustrate: "A vine-dresser, set. -10, of a good 
constitution, fell, and received a simple transverse fracture of the patella, 
on the 15th of January. The medical officer called upon to attend him 
applied first a bandage, for the purpose of drawing together the fragments, 
and afterwards a starched bandage, extending from the toes to the upper 
part of the thigh. The limb was placed upon an inclined plane. The 
patient was visited a few times, but, as he scarcely suffered, the apparatus 
was in no way disturbed. On the first of March (sixteenth day) the at- 
tendant returned to remove the bandage, when the odor arising from the 
limb led him to believe that gangrene had taken place." Dr. Defer, who 
was called, found the toes, which were not covered by the bandage, 
" completely insensible and mummified." The bandage being removed, 
the gangrene was found to extend to within seven inches of the knee. 
The ankle-joint was opened and the ligaments destroyed. The bones of 
the leg were also exposed in their lower third, and the tendons were in 
a sloughy state. Amputation was performed, and the patient recovered. 1 

1 Am. Journ. Med. Sci., vol. xxiv. p. 462, from Gaz. Med., No. 28. 



518 



FRACTURES OF THE PATELLA 



In case 28 of my published cases, plaster of Paris had been upon the 
limb one week when gangrene was threatened, and the plaster had to be 
removed. Cases 87 and 100 illustrate the danger also of tight bandages 
in causing gangrene after a fracture of the patella. 

Dr. Dorsey, of Philadelphia, employed an apparatus which will serve 
to illustrate in its most. simple form the principle of approximating the 
fragments by the use of a splint and bandage. His apparatus consisted 
of a piece of wood half an inch thick and two or three inches wide, and 
long enough to extend from the buttock to the heel ; near the middle of 
this splint, and six inches apart, two bands of strong doubled muslin, a 
yard long, are nailed. The splint is then cushioned, and the limb laid 

Fig. 206. 




John Syng Dorsey's patella splint. 

upon it, a roller being first applied from the ankle to the groin, encom- 
passing the knee in the form of the figure of 8 ; after which the two 
muslin bands are secured across the knee in such a manner as that the 
lower one shall draw down the upper fragment, and the upper one elevate 
the lower fragment. 

Sir Astley Cooper employed two methods of approximating the frag- 
ments, which will be sufficiently illustrated by the following wood-cuts: — ■ 

Fig. 207. 




Sir Astley Cooper's method by circular tapes. 

Fig. 208. 




Sir Astley Cooper's method by a leather counter strap. 



FRACTURES OF THE PATELLA 



519 



Mr. Lonsdale devised a very complicated apparatus. 

Fig. 209. 




Lonsdale's apparatus for fractured patella — A B. Two vertical iron bars, each, supporting a hori- 
zontal one ; these horizontal arms slide upon the vertical bars, but can be secured at any point by the 
screws C D. To the horizontal beams are attached other vertical rods, which are movable, and yet 
fixable by screws, as at E. Finally, to each of these last upright pieces is fixed an iron plate, F F,by 
means of a hinge-joint, which keeps the patella in place. The foot-piece is movable up and down upon 
the main body of the apparatus, and can be made fast at any point, so as to adapt the splint to limbs 
of different lengths. 

The apparatus devised by Lausdale, U. S. N., is more simple than 
Lonsdale's, but both of them can only approximate the fragments when 



Fig. 210. 




Lausdale's apparatus. 



they press very firmly, and then they will necessarily tilt the fragments 
and expose the patient to the risk of ulceration at the points of pressure. 



Wires in semicircular form (A), the posterior part of 
each segment (B) being curved upward and the sides a 
little depressed. A shoulder is formed (C) on each side 
of the segments for the reception of the two straps (D), 
which connect them, and projects far enough on each side 
to permit the wires to be bent downwards at right angles 
with the shoulder, and descend perpendicularly to the slat 
or mortise (E), which is placed near each end of the block 




Beach's apparatus. 



This happened in the only case which I have seen which had been treated 
by Lausdale's apparatus on the fifth day after it was applied. This is 
the case of Assist. Surg. Meyers, reported near the close of this chapter. 



520 



FRACTURES OF THE PATELLA. 



In neither of these forms of apparatus can bandages be properly applied 
to restrain the tilting of the fragments, and to give the knee-joint a 
smooth and equal pressure when it is swollen, as it usually is. 

The apparatus of R. E. Beach, of Illinois, is liable to the same ob- 
jection. 1 



Fig. 212. 




'//////mm I///////////M M: 
Beach's apparatus applied. 



The device of J. H. Hobert Burge, of Brooklyn, in which the frag- 
ments are approximated by carefully adjusted leather pads, operated 
upon by weights, cords, and pulleys, is too complicated, and possesses 
no marked advantages over the simple roller employed in my own dress- 



Fig. 213. 



Fig. 214. 





Turner's apparatus. 



Wyeth's apparatus. 
A. Horseshoe pad. B. 
Posterior splint. C. Ap- 
proximating screw. 



The apparatus of Dr. Turner, 3 of Brooklyn, and of Dr. John A. 
Wyeth, of this city, involve the same principles, and are equally liable 



1 Beach, St. Louis Med. and Surg. Jo-urn., Jan. 1875. 

2 Burge, Med. Record, April 15, 1868. For illustration see 5th ed. p. 471. 



3 Turner, Med. Rec, July, 1867. 



FRACTURES OF THE PATELLA. 521 

to objections, on account of the limited surface against which the pres- 
sure is made. 

In Dr. Wyeth's 1 apparatus the phalanges of the pad furnish a protec- 
tion to the vessels which course along the sides of the knee, and upon which 
the vitality of the integuments of the front of the knee mainly depends. 

Gibson, of St. Louis, has revived, in a modified form, the circular ring 
of Albucasis. 2 Drs. Eve, of Nashville, and Blackman, of Cincinnati, have 
spoken favorably of this method. 3 Its application must, however, be 
limited to such cases as are unattended by inflammation, and can tolerate 
the pressure applied only to a small point of the surface. It is essentially 
the same as Beach's apparatus, but has the advantage of being more 
simple. Its efficiency depends upon its holding firmly upon the fragments, 
and not permitting them to slide from its grasp. All the tendinous 
insertions into the patella are continuous with the anterior margins and 
surface of the bone ; so that there is no natural sulcus to receive the 
ring, or uplift against which the ring or any similar form of dressing can 
obtain a bearing, unless it is very firmly pressed into the tissues above 
and below, as I have before explained. Such pressure as is required in 
the case of a ring, or any similar hard and unyielding mode of pressure, 
will not often be borne by an inflamed and swollen structure. 

Plaster-of-Paris and all other forms of immovable dressing do not 
possess one single point of excellence or advantage. When first applied 
they are liable to constrict the limb dangerously ; and how insidiously 
a fatal gangrene may progress, giving no sign either by pain or general 
disturbance until the destruction is nearly complete, the case seen by 
Defer, and referred to in the preceding pages, will show. The cases 
which I have reported also in the preceding pages demonstrate how 
inefficient these dressings are as means of approximating the fragments; 
the examples of the widest separation being drawn almost exclusively 
from cases treated by the plaster-of-Paris or the silicates. The dress- 
ings, which within a few days or hours are apt to become very tight in 
consequence of the increased swelling, soon begin to loosen, from the 
subsidence of the swelling at first, and finally from atrophy of the 
muscles and other soft tissues, and the limb lies loose in its case, which 
may not even touch the patella, much less make any effective pressure 
upon it. Whatever the result may be under such circumstances, so far 
as the separation of the fragments is concerned, the dressing has nothing 
to do with it. It may be that the final separation will be found to be 
very little, but, if it is, it would have been the same if the limb had been 
laid horizontally in bed without dressings or apparatus of any kind. 

Some have attempted to remedy this serious objection to these dress- 
ings by first applying adhesive plaster in the form of a lock strap, 
and in various other ingenious ways, above and below the fragments. 
I have seen this done repeatedly at Bellevue, and my reported cases 
furnish quite a number of examples ; but, in almost every case, the 
straps soon became painful and had to be removed, and this required 
the opening of the plaster splint or its entire removal. In one of the 

1 Wyeth, Med. Rec, May 11, 1878. 

2 Gibson, Am. Joum. Med. Sci., Jan. 1867, p. 281. 

8 Eve, Blackman, Nashville Journ. Med., Feb. 1867 ; West. Journ. Med., May, 1868. 
34 



522 FRACTURES OF THE PATELLA. 

cases (33) reported by me, the adhesive strips held in place by elastic 
bands caused such excessive pain as demanded the use of hypodermic 
injections of morphine repeatedly, and it resulted in an almost complete 
paralysis of the extensor muscles of the foot, which continued many 
months after the treatment was suspended ; yet from all this there was 
no appreciable gain, inasmuch as the fragments united by ligament with 
the usual amount of separation. Indeed, so far as the position of the 
fragments is concerned, the dressings had only proved mischievous by 
thrusting one of the fragments laterally. 

Plaster-of-Paris is of all the forms of immovable dressings the worst, 
because it is the heaviest; but of them all it must be said that they 
are unnecessarily cumbrous as a form of portative apparatus ; they 
are to some extent dangerous, especially in the hands of inexperienced 
surgeons; they are inefficient as means of approximating the fragments; 
they actually serve but one single purpose, namely, to keep the limb 
straight, and this they do too effectually in many cases, causing an 
unnecessary degree of passive anchylosis. The limb can be maintained 
in a straight position by a much simpler and lighter dressing than a 
plaster-of-Paris splint, and by means which permit it to be daily exam- 
ined and the condition of the fragments noted and corrected, and which 
will allow slight passive motion occasionally to the knee-joint ; a prac- 
tice which has been found in my experience perfectly safe, and useful 
in some measure, so far as the anchylosis is concerned. 

In short, to apply the plaster-of-Paris, and permit the patient to go 
about on crutches, as is generally recommended by its advocates, is to 
abandon, practically, every acknowledged indication of treatment, except 
straightening the limb and securing immobility at the knee-joint. 

The Author's Method of Treatment. — The limb being placed extended, 
with the foot elevated about six or eight inches, a long splint is applied 
to the back of the thigh and leg. This splint may be made of leather, of 
gum shellac cloth (not felt), or of any other material having the neces- 
sary qualities of firmness, lightness, and plasticity, so that it can be prop- 
erly moulded to the limb. Of late I have preferred the gum shellac 
cloth as possessing in a greater degree the necessary qualities than either 
of the others. The splint should be long enough to extend from above 
the middle of the thigh to two or three inches above the heel. Its width 
should be sufficient to inclose the posterior semi-diameter of the leg and 
thigh. It should be placed in hot water, and then moulded to the back 
of the limb : only that it is rather better not to fit it accurately to the 
popliteal space, in order that a small amount of cotton batting may be 
placed between the splint and the skin. 

The splint should then be removed ; and, if made of shellac cloth, in 
a few minutes it will be sufficiently hard to retain its form. It is now 
covered completely with a firm cotton or woollen sack, and the sack stitched 
along the back of the splint. The splint having been curved to fit the 
circumference of the limb, the sack must hang loose across the concave 
surface of the splint, so that the limb may be allowed to fall back to the 
splint, but the ends of the sack may be drawn and stitched tightly. 

One object of the covering is to furnish a protection to the skin against 
the splint ; but the chief object is to supply a basis to which the bandage, 
which is to inclose the limb and splint, may be stitched. 



FRACTURES OF THE PATELLA. 523 

The splint must be applied while the limb is in the position already 
described, a small wad of cotton batting having been placed in the ham. 
A roller, made of unglazed cotton cloth, is then turned around the leg 
and splint to within about three inches of the knee, and another from 
the upper end of the splint over the splint and thigh to within three inches 
of the knee. While an assistant approximates the fragments with his 

Fig. 215. 




The Author's Mode of Dressing. — (The final turns of the roller, in front of the knee, 
are not shown in the woodcut. ) 

fingers, the surgeon makes two or three turns w r ith a third roller around 
the limb and splint, close above the knee ; after which the roller descends 
below the knee, and an equal number of circular turns are made close 
below the lower fragment of the patella ; and finally, a succession of 
oblique and circular turns are made above and below the fragments, 
which turns are to approach each other in front until the whole of the 
patella is covered — the last turns being again circular. The dressing 
now being completed, the rollers are carefully stitched to the cover of 
the splint through its whole length, on both sides ; and the limb is left- 
supported in the elevated position by a suspending apparatus, or by some 
other mode which will insure its maintenance in this position. 

I have been thus particular in my description because all of my readers 
may not have had experience in the application of bandages, and because 
to many of the details I attach importance. A few words of explanation 
of some of these points may not be amiss. 

The cotton cloth roller is preferred, especially for the purpose of 
approximating the fragments, because, if unglazed it yields a little, and 
adapts itself smoothly to the skin, even sinking down a little just above 
and below the patella, thus rendering it less liable to slide over. Re- 
versed turns are omitted altogether, because they cause sharp cords 
where they are folded, and sometimes produce painful constrictions and 
excoriations. Adhesive strips, recommended by me in the first edition 
of this work, I have long since laid aside. They are just as liable to 
slide, they are apt to cut at their free margins, and they have to be 
raised up from time to time to be tightened, and they cannot be stitched 
and thus permanently secured to the cover of the splint. No pads 
above and below the knee are recommended because they are apt to 
become displaced, and if they remain in place they no more effectually 
press the fragments together than does the cotton roller. No pad is 
placed in front of the patella because the last turns of the roller press 
back the fragments as effectually as a pad. Care must be taken when 



524 FRACTURES OF THE PATELLA. 

the roller is applied and the fragments are approximated, that the loose 
skin in front of the patella is not pressed between the fragments. No 
lotions must be applied, to saturate the dressings. They render the skin 
more liable to excoriations, and they are in no way useful. 

All that remains to be done is easily said. On the second or third day 
the swelling of the knee will be found, probably, to have subsided some- 
what, and the oblique turns of the bandage from above and below the pa- 
tella will need to be tightened. This will be done by over-stitching, with 
strong thread, the oblique turns ; taking care to do this on both sides 
and so far back that the doubling of the cloth will not be over the sides 
of the exposed portions of the limb. The same thing may be required 
to be done every day, or every second or third day, for two or four 
weeks. Meanwhile it will generally be found — for the position of the 
fragments can always be felt — that the space between them has not been 
increased, and in most cases that it has sensibly diminished from the day 
of their first adjustment. 

At the end of about four weeks the apparatus should be removed care- 
fully. It is now observed generally, that the knee is pretty stiff, and 
that the upper fragment cannot without considerable force be displaced 
in any direction. It is anchylosed, and there is very little danger that 
it will thereafter draw up further, and it is not probable that any appa- 
ratus will make it descend. But as a matter of safety, an assistant 
should now press the upper fragment gently downwards while the sur- 
geon flexes the knee very slightly, so as to diminish its stiffness. He 
ought, in doing this, never to cause pain or to use any degree of force. 

The splint is then to be reapplied in the same manner as before. 
Daily, hereafter, the splint should be removed with the same care, and 
the limb gently flexed. In the mean while the patient may go about 
upon crutches if he chooses. 

In six or eight weeks the bond of union may be considered completed, 
and the patient may be dismissed from the immediate care of the sur- 
geon, but not until he has been fully informed of the danger of a rupture 
of the new ligament, and has been provided Avith the means of protection 
as far as possible. He must be taught that for the next three or four 
months this danger is great ; and that any sudden flexion of the limb may 
cause it ; and indeed that it may be caused by simple muscular action, 
when the limb is not flexed. During this period he should walk only 
upon crutches, and the knee-joint should be constantly supported, unless 
he is completely at rest. 

The knee-caps usually furnished for this purpose are wholly unrelia- 
ble. They allow the knee to bend too freely. Indeed, nothing but an 
inflexible splint can insure safety ; and the same splint employed in the 
treatment, reduced one-half in length and secured by straps and buckles, 
is the best I have yet employed. 

Under no circumstances, in my opinion, is the surgeon justified in 
attempting to overcome the anchylosis by force, either with or without 
an anaesthetic. The chances are more than equal that he would substi- 
tute a ruptured ligament and an ununited patella for an anchylosed knee. 
I have been informed that this accident actually occurred at one of our 
>city hospitals a few years ago, in the presence of a class of students. In 



FRACTURES OF THE PATELLA. 



525 



time, and generally within a year or two, the anchylosis will disappear 
under careful and moderate use of the limb. 

It will be seen that I no longer recommend the wooden inclined plane 
(Fig. 216) in all cases, as I have done in my earlier editions. The prin- 
ciple of its construction is correct, and the results have been satisfactory, 
but it is unnecessarily cumbrous for a majority of recent and primary 
accidents, and I reserve it now only for exceptional cases, such, for ex- 
ample, as those in which the separation is very great, or the inflammation 
and swelling are unusual. 

Fig. 216. 




The author's wooden inclined plane for fractures of the patella. 

Mr. Hutchinson, of London, has of late omitted to elevate the foot in 
the treatment of this fracture, and he thinks that the fragments are 
maintained in apposition with quite as much ease. 1 I cannot agree with 
him that nothing is ever gained by the elevation of the foot. On the 
contrary, in the treatment of a certain proportion of cases this position 
will be found essential to the best success, while in others it may be of 
little consequence whether the foot is elevated or not. 

The dressing and apparatus employed by Wood, of King's College 
Hospital, are very similar to my own wooden inclined plane, but, as will 
be seen by the accompanying drawing, the splint is only five or six 
inches wide. Dr. Wood has substituted hooks for the notches. 2 

I will add now, although somewhat out of place, what that distin- 
guished surgeon, Corradi, of Bologna, has said on the subject of fibrous 
and bony union: 3 — 

" Long before Ledeau and Pott, a Venetian surgeon, Pietro de Al- 
bertis, had made the observation that it was not necessary to the freedom 
of ordinary motion that a perfect union of the fracture of the patella 
should take place. 

" Flajani, from his own experience, was convinced that the danger of 



1 Hutchinson, London Hosp. Reports, vol. xi. 2 Fergusson's Surgery, p. 307. 

3 Delia Chirurgia in Italia, dagli ultimi anni del secolo scorso fino al presente. 
Commentario di Alfonso Corradi, p. 216. (A concour prize essay, approved by the 
Med. Chir. Soc. of Bologna, An. 1870.) The author refers to a letter written and 
published by Albertis in defence of Andrea "Veronica ; being a dissertation on the 
fracture of the patella, printed at Macerata in 1695. 



526 



FRACTURES OF THE PATELLA. 



anchylosis and lameness was diminished by adopting no other means 
than the simple and natural situation of the parts, after having at first 
applied emollient or resolvent remedies," etc. ; enjoining also early 
passive motion. '" These views of Flajani were corroborated by Man- 
zotti" (Dissert, on Frac. of Patella, Milan, 1790), "and subsequently 
confirmed by modern surgeons, particularly by Velpeau. It is proper 
to point to the fact that the Roman professor, in the same way as Pott, 

Fig. 217. 




Wood's apparatus. 



abandoned apparatus, not, as some one has strangely asserted, for the 
purpose of increasing the separation of the fragments, but because he 
regarded position alone as sufficiently efficacious in the approximation 
of the fragments ; but when these fragments are very much separated, 
position is not always efficient, nor are we much aided by apparatus, 
even although we employ the best." 

Treatment of a Refracture or Rupture of the New Ligament. — I now 
come to consider briefly the treatment of a refracture of the patella, or 
of a rupture of the newly-formed ligament. 

In all cases the patient should, as soon as possible, be subjected to the 
same plan as I have recommended for original fractures, only that the 
treatment will have to be continued longer, and w T ith smaller hope of a 
reunion. It is here when the separation is great, and in old cases of 
ununited fracture, that I could justify the use of Malgaigne's hooks ; but 
of their value even in these cases I am not prepared to speak confidently. 

In employing Malgaigne's hooks the lower hooks are made to overlap, 
or grasp the lower margin of the lower fragment, and the upper hooks 
are projected forcibly into the top and front of the upper fragment. The 
upper hooks are therefore quite apt to loosen and slide. 

The time always arrives, according to my experience, both in primary 
and secondary fractures, in which supporting and retentive apparatus is 
worse than useless. The period is within five months after the original 
accident, or within about three months after the union of the fragments; 
or within about the same period, if no union ever takes place, either 
fibrous or bony. 

A reference to some of the cases I have reported, and especially to 
that of Assistant Surgeon Myers, of the United States Navy (case 40), 
will illustrate the importance of removing all support after a time, and 
teaching the muscles to rely upon themselves alone. Under proper and 
free use of the limb, aided by friction, electricity, etc., the muscles will 
become developed in size and strength, and through their remaining 



FRACTURES OF THE PATELLA. 527 

attachments to the sides and front of the leg, below the knee, will give 
to the patient often a very useful limb. The case is as follows : — 

Assistant Surgeon T. D. Myers, get. 29, broke his right patella May 
19, 1874, when returning from the U. S. ship Kearsage, from mus- 
cular action in attempting to save himself from a fall. The fracture 
was transverse, and below the middle — at the upper end of the lower 
fourth. The fragments at once separated fully four and a half inches. 
Surgeon Bloodgood in charge. May 21st he was sent to the hospital at 
Yokohama. A long posterior splint was applied and the fragments 
secured with a figure-of-8 bandage. May 24th, Lausdale's apparatus 
was applied. This was worn five days, when it was found to have 
caused a slight ulceration above the upper fragment, and it was removed. 
A straight splint, secured at the knee by adhesive strips, was substituted, 
and kept on several weeks ; and soon after he began to walk, the frag- 
ments being united by a ligament one-half an inch in length on the inside, 
and one-quarter of an inch on the outside. 

August 2, 1874, seventy-five days after the first injury was re- 
ceived, and not long after he began to walk, he slipped and broke it 
again from muscular action. He was still in the hospital at Yokohama. 
A plaster-of-Paris splint was now applied, which was renewed once in 
about eight days, and finally removed at the end of eight weeks. While 
this splint was on the limb he was allowed to go about on crutches. 
On removal it was found that no union of any kind had taken place. 
From this time forwards, a period of over five months and two weeks, 
he supported the limb with a leather splint, and walked about on 
crutches or with a cane. He consulted me March 17, 1875. I found 
the fragments separated four and a half inches, with very little motion 
at the knee-joint. Could not detect any bond of union. I advised the 
removal of the leather splint, and daily use of the limb by passive 
motion and active exercise in walking, also electricity, shampooing, etc. 

In a letter from him, dated May 23, 1875, he says : " Since consult- 
ing you, March 17, 1875, I have steadily pursued the plan of treatment 
suggested by you," etc. " The functions of the limb have gradually 
returned, till now I am able to walk very well, with very little or no 
limping." . . . " The atrophy of the muscles is gradually disappearing." 
. . . And he concludes with expressions of gratitude for the happy 
result of the change in the mode of treatment. 

Post, of New York, has reported three cases of compound fracture of the 
patella extending into the knee-joint, brought to a successful termination. 1 

In a case mentioned by Eve, of Augusta, occasioned by the kick of a 
horse, and in which amputation became necessary on the tenth day, 
" the knee-joint was found filled with dark grumous blood ; a portion of 
the cartilage of the internal condyle of the os femoris was chipped off, 
and the patella broken into a number of fragments." 2 

Lewitt, of Michigan, has related a case of fracture in a lad set. 16, 
produced by striking his knee against a piece of timber, which resulted 
in suppuration of the knee-joint, but from which he finally recovered 

1 Post, New York Journ. of Med., vol. ii., first series, p. 367. 

2 Eve, Southern Med. and Surg. Journ., 1848 ; also Bost. Med. Journ., vol. xxxvii. 
p. 427. 



528 FRACTURES OF THE TIBIA. 

with the perfect use of the limb. The fracture of the patella was 
oblique, traversing only its upper and outer margin, and it was never 
much displaced. 1 

Dr. Levergood, of Pennsylvania, has reported a similar case, in which 
it became necessary to open the joint freely, yet it was followed by an 
excellent recovery, only a slight anchylosis remaining at the knee-joint. 2 

Dr. E. Mason has reported a case in which considerable anchylosis 
resulted from the plaster-of-Paris treatment. A refracture occurred, 
and although no blow was inflicted directly upon the knee, the adhesions 
which had ensued upon the previous fracture had so united the skin and 
subjacent tissues that the soft parts gave way with the bone, opening 
the joint freely. Extensive suppuration ensued and the patient died. 3 

Thomas A. Gallagher, set. IT, fell, May 24, 1880, thirty feet, striking 
with his right knee upon a rock, and breaking the right patella at its 
lower and outer third into several fragments — the wound communicating 
with the joint. He was placed immediately under my charge, and the 
limb was laid at rest in the horizontal position. No bandages or other 
restraints were employed. On about the fifth day suppuration occurred 
in the joint, and the limb became greatly swollen. I opened the joint 
freely, removed all of the small fragments, and made a counter-opening, 
through which a large drainage tube was passed. Hot water fomenta- 
tions were applied to the whole limb, and the knee-joint was daily washed 
thoroughly with a weak solution of carbolic acid. The inflammation and 
suppuration began to subside from this date, and on the first day of July, 
thirty- seven days after the accident, he was walking on crutches, the 
wounds having nearly closed, the joint being free from inflammation, and 
sufficient motion remaining to render it probable that the functions of the 
joint will be completely restored. 



CHAPTEE XXXI. 

FRACTURES OF THE TIBIA. 

Development of the Tibia. — The tibia is formed, usually, from three 
centres of ossification — one for the shaft, and one for either extremity. 
Ossification commences in the shaft at or about the fifth week of foetal 
life. In the upper epiphysis it appears at birth, and unites with the 
shaft at about the twenty-fifth year. Generally it forms the tubercle, 
but occasionally the tubercle has a distinct point of ossification. The 
lower epiphysis commences to ossify during the second year, and unites 
with the shaft at about the twentieth year. The malleolus internus is 
occasionally formed from an independent centre. 

Etiology of Fractures of the Tibia. — Fractures of the tibia alone are, 

1 Lewitt, Medical Independent, Sept. 1856. 

2 Levergood, Amer. Journ. Med. ScL, Jan. 1860. 

3 Mason, N. Y. Journ. Med., April, 1875, p. 416. 



FEACTURES OF THE TIBIA 



529 



218. 



in a large majority of cases, produced by direct blows, such as the kick 
of a horse, or a blow from a stick of wood ; in one instance I have seen 
it broken by a kick from a Dutchman's boot. It is occasionally broken 
by a fall upon the foot, the force of the impulse being expended before 
the fibula gives way, but almost always the fibula breaks at the same 
moment, or immediately after the fracture has taken place in the tibia. 

Dr. Proudfoot, of New York, has reported an example of fracture of 
the tibia in utero, produced in the sixth month of pregnancy, by violent 
pressure upon the abdomen. 1 

Pathology, Division, etc. — In an analysis of twenty-seven fractures 
of the tibia, not including fractures of the malleoli, six were found to 
have occurred in the upper third, eleven in the middle 
third, and eight in the lower third. Six of the twenty- 
seven are known to have been transverse, or only slightly 
oblique. It is probable, also, that several of the remain- 
der were transverse. In this respect, therefore, fractures 
of the tibia alone will be found to differ materially from 
fractures of the tibia and fibula ; but it is only in accord- 
ance with the general observation that indirect blows 
produce almost constantly oblique fractures, and direct 
blows somewhat more frequently transverse. 

Many examples of fractures of the tibia extending into 
the knee-joint are recorded by surgeons, most of which 
were compound, or otherwise seriously complicated, so 
as to render amputation necessary, and the consideration 
of which scarcely belongs properly to a treatise upon 
fractures. 

The malleolus internus is broken frequently at the 
same time that the ankle-joint is dislocated, and this 
accident will be considered in that connection. 

Separation of Epiphyses. — We have already men- 
tioned that Madame Lachapelle has reported a case of 
separation of the upper epiphysis of the tibia, and of the 
lower epiphysis of the femur, occasioned by pulling at 
the foot during birth. 

Dr. Yoss, of New York, has seen a separation of the 
lower epiphysis in a boy 14 years old, who in falling had 
caught his foot between two blocks of wood. The upper fragment pro- 
truded through the skin. Reduction was effected, but subsequently a 
portion of the epiphysis became necrosed and was removed. He finally 
recovered with a useful joint. 2 

Dr. R. W. Smith has reported a similar case in a boy 16 years of 
age, and which, having occurred six months before, remained unreduced. 
The lower end of the shaft was displaced forwards. Richard Quain 
records one other example, in a lad 17 years old, which was easily re- 
duced and maintained in position. 3 





Development of 
the tibia. (From 
Gray.) 



1 Proudfoot, Bost. Med. and Surg. Jouru., vol. xxxv. p. 268, 1846 ; from New York 
Journ. Med. 

2 Voss, N. Y. Journ. Med., Nov. 1865, p. 133. 

3 New York Journ. Med., June, 1868 ; from British Med. Journ., Aug. 31, 1867. 



530 FRACTURES OF THE TIBIA. 

Prognosis. — No shortening can occur in this fracture unless one or 
both ends of the fibula are displaced, a complication which I have noticed 
in two instances, but in neither case did the shortening exceed one- 
quarter of an inch ; unless, indeed, the fibula bends and remains bent, or 
the comminution and direction of the fracture is such at either end as to 
allow the femur or the astragalus to become impacted. I have never 
recognized either of these conditions. 

Occasionally the upper fragment has been slightly displaced forwards. 
With these exceptions, and one other of delayed union which I shall 
presently mention, this bone, in my experience, has been found to unite 
promptly and without any appreciable deformity. Other surgeons have 
noticed occasionally that the upper end of the lower fragment has be- 
come displaced toward the fibula. 

Delayed union has been observed pretty frequently in fractures of 
the upper third of the tibia, of which circumstance M. Duplay, according 
to a reference to one of his clinical lectures, contained in the Lancet, 
May 18, 1878, makes the following observations : — 

" In many of these cases there is no constitutional vice to which it 
can be attributed, and the usual local causes of non-union are absent. It 
has been stated that fractures above the entrance of the nutrient artery, 
which is directed downwards, unite less readily than those below it on 
account of their relation to the blood supply of the bone. But the upper 
end of the tibia is the most vascular part of the whole bone, and its 
nutrition may, therefore, be presumed to be in a very active condition. 
He regards, however, this very vascularity of the bone as the cause of 
the difficulty of union, as, when fractured, the great number of torn ves- 
sels pour out an unusually large quantity of blood between and around 
the broken ends of the bone, which coagulates, and thus impedes or 
altogether prevents the thorough organization and ossification of the 
callus. He states that in these cases he has met with distinct evidence 
of this extensive effusion of blood." 

I have met with examples of delayed union in this portion of the bone, 
of some of which I shall hereafter speak more particularly. 

Muhlenberg, in his tables comprising 656 examples of delayed and 
non-union of long bones, records 84 of the tibia alone ; of which number 
2 were cured by friction, 7 by mechanical appliances, 3 by seton, 11 by 
resection, and 15 by drilling. 1 

Dr. Donne, of Louisville, has reported an example of delayed union 
in a simple transverse fracture of the upper end of the tibia. The man 
was intemperate. Ten weeks after the accident no union had occurred. Dr. 
Donne introduced a seton, and in about six weeks the fragments were firm. 2 

If the fracture extends into either the knee or ankle-joint, the danger 
of anchylosis is imminent, yet experience has shown that it may some- 
times be avoided. 

When the malleolus is broken off, it generally becomes slightly dis- 
placed downwards, and in this position a complete bony or ligamentous 
union of the fragments generally takes place. 

Treatment. — The tendency to displacement, in a fracture of the tibia, 

1 Muhlenberg, Agnew's Surg., op. cit., vol. ii. p. 806. 

2 Donne, Amer. Journ. Med. Sci., vol. xxviii. p. 524 ; from Western Journ. Med. 
and Surg., Aug. 1841. 



FRACTURES OF THE TIBIA. 531 

is usually so slight, if it exists at all, that simple dressings, light splints 
of leather, felt, or binder's board, with rest in the horizontal posture 
upon a pillow, fulfil nearly all the indications which are present. The 
following cases will illustrate the usual course of these accidents. 

Mrs. W. fell, Oct. 19, 1848, striking on her right knee, breaking the 
tibia transversely just below the tuberosity. 

The fall w T as the result of a misstep on level ground, and was attended 
with only slight bruising of the soft parts. She says that on attempting 
to rise she discovered what had happened, the bone projecting very dis- 
tinctly, and she pushed and pulled it into place w T ith her own hands. 

I dressed the limb by laying it upon a pillow, outside of which were 
placed two broad deal splints, tying the Avhole snugly together with 
several strips of bandage. At a later period the leg and thigh were laid 
over a double-inclined plane. 

At the end of six weeks all dressings were removed, and the frag- 
ments were found to have united firmly, and so perfectly" that the point 
of fracture could not be traced. 

Peter Hamil, aet. 29, was admitted into the hospital Aug. 31, 1819, 
with an injury to his left leg, which had occurred two days before. A 
young surgeon had examined the limb, and thought the femur was broken 
just above the joint. He had applied a roller from the toes to the thigh ; 
and to the thigh were applied lateral splints. These dressings were on 
the limb at the time of his admission, and were not removed until the 
next day. I could not then discover any fracture or displacement, and 
the dressings were discontinued, the limb being merely laid upon pillows. 

Oct. 4, when examining the limb, I detected a slipping sensation, like 
that produced in a false joint, through the upper end of the tibia, and I 
now easily understood what had been mistaken for a fracture of the 
femur. It was a transverse fracture through the upper end of the tibia, 
and without displacement. 

No splints were afterwards applied, and on the 25th of November, 
three months after admission, he was dismissed, the motion between the 
fragments having ceased, but the knee still remaining quite stiff. 

The presence of inflammation, with other complications, may, how- 
ever, occasionally render the treatment more difficult and the results less 
satisfactory. 

John Mahan, aet. 39, admitted to the hospital Feb. 16, 1853, with a 
compound fracture of the right tibia, near the middle of the leg. The 
bone was broken by the kick of a Dutchman. I found the limb much 
swollen and very painful, and I laid it carefully over a double-inclined 
plane, and directed cold water irrigations : I also directed morphia in 
full doses. The inflammation for several days threatened the complete 
loss of his limb. On the tenth day the distal end of the upper frag- 
ment was projecting in front of the lower, and I depressed the angle of 
the splint and made moderate pressure upon the upper fragment. On 
the twentieth day the fragments were bent backwards, and I placed a 
compress behind. On the thirty-seventh day we took the limb from the 
inclined plane, and trusted alone to side splints. On the forty-fifth day 
we removed all dressings. The fragments had not united. The limb 
w T as then laid upon a pillow, and six days later a firm gutta-percha splint 
was applied for the purpose of steadying the bone, but the splint was 



532 FRACTURES OF THE TIBIA. 

removed daily in order that the leg might be bathed and rubbed. He 
was allowed to sit up. On the fifty-ninth day motion could still be per- 
ceived between the fragments, and he was directed to use crutches. On 
the ninety-third day the union was found to be firm, the upper fragment 
remaining slightly displaced forwards. 

In case the fracture extends into the knee-joint, it is best to lay the 
limb upon pillows in a nicely cushioned box, and nearly straight. No 
extension or counter-extension is necessary here any more than in other 
fractures of the tibia alone, nor are lateral splints or rollers necessary 
or proper at first as a general rule ; but especial attention should con- 
stantly be given to the prevention of inflammation, and of subsequent 
anchylosis. The omission to employ splints in a case of this kind was 
charged against a surgeon in Vermont as evidence of malpractice. I 
am happy to say, however, that, in this particular case, he was sustained 
by the testimony of the medical men and by the verdict of the jury ; 
but the attempt which the reporter has made to defend this as a univer- 
sal practice in fractures of the leg, or of the tibia alone, is unfortunate, 
and evinces a lack of practical experience. 1 

Whatever position is adopted, and whatever means of support or 
retention are employed, if bandages and splints are applied tightly or 
injudiciously, great suffering and irreparable mischief to the knee-joint 
may be the consequence. 

A man, set. 23, entered the Pennsylvania Hospital, July 18, 1839, 
with an oblique fracture through the head of the tibia. A physician 
had applied a bandage and splint to the leg, and sent him twenty miles 
to the city, and, on examination after his arrival, the whole limb as high 
as the groin was much swollen, red, and excessively painful. The knee- 
joint was distended and very tender. All dressings were immediately 
removed, and the limb laid in a fracture-box slightly elevated at the foot; 
cool lotions were applied, and the patient was freely bled, both from the 
arm and by the application of leeches. The limb was kept in this posi- 
tion about six weeks, and at the end of two or three weeks more he was 
dismissed, cured. Dr. Norris, who was the hospital surgeon in attendance, 
has, in his report of the case, very properly taken this occasion to warn sur- 
geons of the danger of excessive bandaging and splinting in this kind of 
fracture, as well as in all other fractures of the lower extremities. 2 

Fractures of the malleolus, unaccompanied by any other accident, 
demand only that the limb should be laid upon its outer or fibular side, 
with the foot so supported that it shall incline inwards toward the tibia. 
In this simple disposition of the limb we have done all that can be done 
by any mechanical contrivance toward approaching the lower fragment 
to the shaft from which it has been broken. 

Treatment of Delayed Union. — If improving the general condition 
of the patient by allowing him to go about with or without splints, or 
frictions of the ununited surfaces, do not succeed, we may be obliged to 
resort to other, strictly surgical expedients. It has already been stated 
that Dr. Donne, of Louisville, resorted successfully to the seton. I have 
succeeded by other means. 

1 Boston Med. Journ., vol. liv. p. 1, March, 1856. 

2 Norris, Amer. Journ. of Med. Sci., vol. xxiii. p. 291. 



FRACTURES OF THE FIBULA. 533 

Mr. H. Lichstenstein, set. 40, broke his left tibia Aug. 6, 1866, by 
twisting his leg violently in the upper third. There was only a slight 
forward displacement of the lower fragments. His surgeon dressed it 
with Swinburne's extension apparatus, without side splints. I was called 
to see him, in consultation, sixteen weeks after the accident occurred, and 
found the fragments perfectly movable. He had not yet left his bed. I 
advised a firm gutta-percha splint to be moulded to the back of his thigh 
and leg, and that he should go about on crutches. In six weeks it was 
united and firm. 

In the case of John J. Blair, of Brooklyn, with a transverse fracture 
just below the tubercle of the tibia, the union was delayed many months. 
He placed himself under my charge at St. Elizabeth's Hospital, in this 
city, and as he had been walking for some time, and his health was 
good, I perforated the bone with Brainard's drill several times, and, bind- 
ing a firm splint upon the back of his thigh and leg, he was laid in bed. 
After the first week I pushed an ordinary shawl-pin between the frag- 
ments, and left it in place three days. This was repeated several 
times, and at the end of a few weeks union was complete. 



CHAPTEE XXXII. 

FRACTURES OF THE FIBULA. 

Development of the Fibula. — The fibula is formed from Fig. 219. 



^0\ 



«i 



three centres of ossification — one for the shaft, and one 
for each extremity. Bone begins to be deposited in the 
shaft at about the sixth week of foetal life, in the lower 
extremity during the second year, and in the upper ex- 
tremity during the fourth year. The lower epiphysis 
unites with the shaft about the twentieth year, and the 
upper about the twenty-fifth year. 

I have not found any recorded examples of separation 
of these epiphyses. 

Causes of Fracture. — In a record of forty-eight cases 
I have been able to ascertain the cause satisfactorily in 
thirty-two, of which number six were the results of falls 
directly upon the bottom of the foot, but which were 
probably accompanied by a twist of the foot, eleven of 
a slip of the foot in walking on level ground or on ground 
only slightly irregular, and fifteen of direct blows. 

Pathology. — In all of the fractures which have been 
produced by falls upon the bottom of the foot, and in all 
except one produced by a slip of the foot, the accident 
was accompanied by a partial dislocation of the ankle ; 
the foot being turned outwards. In the one exceptional 
case mentioned, the dislocation may also have occurred, 
but the fact is not known. thfJbuu^rom 

Both Malgaigne and Dupuytren have noticed a dislo- G ray.) U * 



534 



FRACTURES OF THE FIBULA. 



cation in the opposite direction, or a turning of the foot inwards, more 
often than a turning outwards. I cannot think their observations were 
carefully made. 

Moreover, in at least ten of the fifteen fractures produced by direct 
blows, the tibia has been thrown more or less inwards, and consequently 
the foot has turned out. Occasionally the tibia slides a little forwards 
upon the astragalus. But this seldom happens as the primary accident; 
it occurs later, perhaps within the first ten days after the accident, 
when the heel has been insufficiently supported. 

In thirty-seven examples the fracture of the fibula has taken place 
within from two to five inches of the lower end of the bone. Three 
times the external malleolus was broken oft', and eight times the internal 
malleolus. 

Five of the fractures occurring in consequence of direct blows were 
compound, and one was also comminuted. 

It will be seen, therefore, that the most frequent form of fracture of the 
fibula is that first described by Pott as follows : " This is the case when, 
by leaping or jumping, the fibula breaks in the weak part already men- 
tioned ; that is, within two or three inches of its lower extremity. When 
this happens the inferior fractured end of the fibula falls inward toward 
the tibia, that extremity of the bone which forms the outer ankle is turned 
somewhat outward and upward, and the tibia, having lost its proper sup- 
port, and not being of itself capable of steadily preserving its true per- 
pendicular bearing, is forced oft' from the astragalus in- 
wards, by which means the weak bursal or common liga- 
ment of the joint is violently stretched, if not torn, and 
the strong ones, which fasten the tibia to the astragalus 
and os calcis, are always lacerated ; thus producing at the 
same time a perfect fracture and a partial dislocation, to 
which is sometimes added a w r ound in the integuments made 
by the bone at the inner ankle." 1 

Prognosis —In a majority of cases, where the fibula 
has been broken from two to five inches above the lower 
end, the fragments have united inclined toward or resting 
against the tibia ; occasionally I have seen them displaced 
backwards or forwards. Once the fibula refused to unite 
altogether. 

The maleoli have generally united nearly or quite in 
place, but in two instances the external malleolus has been 
found displaced very much downwards. 

Of the compound fractures, two required amputation, 
one was treated by resection of the lower end of the tibia, 
and two died without any operation. Douglas has re- 
ported a case of compound dislocation with fracture of the fibula, which 
being reduced, he was able to save the limb, but not without much diffi- 
culty, and the ankle remained stiff. 2 Other surgeons have met with 



220. 




Fracture of fibula 
near lower end. 



1 The Chivurgical Works of Percival Pott, F.R.S., Surgeon to St. Bartholomew's 
Hospital. First Amer. ed., 1819, p. 248. 

2 Boston Med. and Surg. Journ., vol. xxxiv. p. 336, from Southern Journ. of Med. 



FRACTURES OF THE FIBULA. 535 

similar success, but I shall refer to this subject again under the head of 
compound dislocations. 

Of those which recovered, forty-six in number, twelve have been found 
to have more or less unnatural prominence of the internal malleolus, and 
in two of these the malleolus, or lower end of the tibia, projects very 
much. In nearly all of these latter examples the foot appears somewhat 
inclined outwards. 

Generally the ankle-joint has remained stiff for some time after the 
bandages have been removed ; and probably in all cases in which the 
accident was accompanied by a dislocation of the tibia. But this stiff- 
ness has usually disappeared after a few weeks or months. Twice I 
have noticed considerable stiffness after about six months ; three times 
after one year ; in one case after two years ; and in one case after twenty 
years the ankle would occasionally swell, and become quite stiff. In one 
case it remained almost immovable after twenty years ; and in a still 
more remarkable instance, I examined the limb thirty years after the 
accident, when the man was sixty-three years old, and although there ex- 
isted no swelling or deformity, yet this leg was not as muscular as the 
other, and he declared that up to this time the ankle remained quite 
tender to the touch, and that occasionally it became painful. 

When I come to speak of dislocation of the ankle, I shall adopt the 
usual nomenclature, and shall name all those dislocations in which the 
tibia projects inwards from the foot, " inward dislocations of the tibia ;" 
yet I have some doubts as to the propriety of calling this a dislocation, 
either partial or complete. This accident seems to me to have been in 
general rather a lateral rotation of the foot, or of the astragalus, upon 
the lower articulating surfaces of the tibia and fibula. Of all the gin- 
glymoid joints, the ankle approaches most nearly in form to a ball and 
socket-joint, in consequence especially of the marked prolongations of 
the malleolus internus and externus. In other ginglymoicl articulations 
lateral displacements are not unfrequent, but lateral rotation can scarcely 
by any accident occur. Here, however, the reverse holds true ; lateral 
displacement is difficult, w T hile lateral rotation is comparatively easy of 
accomplishment. 

The majority of cases which occur, involving a disturbance of the 
relative position of the ankle-joint surfaces, are, I am satisfied, of this 
latter character, viz., lateral rotations within the capsule, rather than 
true dislocations ; and although the restoration of the joint surfaces to 
position is, in general, easily accomplished, yet in consequence of either 
a fracture of the fibula or malleolus internus, or of a rupture of the in- 
ternal lateral ligaments, it will generally happen that some deformity 
will remain. The fragments of the fibula will fall inwards toward the 
tibia, and the foot, unsupported by either its fibula or its internal liga- 
ments, will incline perceptibly outw T ards. Nor can this be wholly pre- 
vented, in most cases, by any mechanical contrivance. Indeed, it would 
be easy to demonstrate, as I have often done to my pupils, that even 
Dupuytren's splint, heretofore so much employed in this accident, must 
fail of success in a great majority of cases ; since the subsequent de- 
formity is due less to the fracture of the fibula and its consequent dis- 
placement than to the loss of the internal ligaments, which loss nature 



536 



FRACTURES OF THE FIBULA. 



can seldom fully repair. As further evidence of the correctness of this 
view, I will state that in three of the examples in which I have found 
the fractured fibula united and resting against the tibia, the motions of 
the ankle-joint have been completely recovered. 

If, however, it were true that a fracture and displacement of the 
fibula is the sole or essential cause of the subsequent deformity, it would 
still be found often impracticable to avoid the maiming, since it would 
still remain impossible to lift the broken ends from the tibia, against 
which, or in the direction toward which, they are so prone to fall. In- 
version of the foot does not accomplish it, nor have I ever been able to 
make anything but the most trivial impression upon the upper end of 
the lower fragment by pressure upon the lower extremity of the fibula. 

I think too much confidence has been placed in the efficiency of 
" Dupuytren's splint." I believe, indeed, that this splint is, in many 
cases, a very appropriate means of support and retention after this acci- 
dent ; but I doubt whether it is able to accomplish all that its illustrious 
inventor proposed, and especially in those cases in which, the fibula being 
broken, and the internal lateral ligaments torn, the astragalus is dis- 
posed to glide backwards ; of which I have seen several examples, some 
of which have left a permanent and serious deformity, in the elongation 
of the heel and shortening of the foot in front of the tibia. It does not 
appear that either Pott or Dupuytren were aware of this form of dis- 
placement from this cause. 

Treatment. — Dupuytren's mode of dressing is essentially as follows: — 
A pad, or long junk, made of a piece of cotton cloth, stuffed with 
cotton batting, is constructed of sufficient length to extend from the con- 
dyles of the femur to a point just above the malleolus internus. This 
pad must be about five or six inches in width, and thicker 
by two or three inches at its lower than its upper end. 
This is to be laid upon the inside of the leg, with its base 
or thickest portion resting against the tibia just above the 
internal malleolus. Over this pad is to be placed a long 
firm splint, extending also from above the knee to three 
inches beyond the bottom of the foot. With a few turns 
of a roller the upper end of the splint will now be made 
fast to the knee, and with a second roller the lower end 
must be secured to the foot. The application of this last 
bandage requires, however, some care in its adjustment. 
Its purpose is simply to rotate the foot inwards, while at 
the same time the tibia is pressed outwards ; and to this 
end it must be applied in the form of a figure-of-8 over 
both splint and foot, embracing alternately the heel and 
the instep. In order to be effectual, it must be drawn 
pretty firmly, and no portion of the bandage must pass 
higher than the malleolus externus. In some surgical books 
I have seen this apparatus represented w T ith a roller em- 
bracing the whole length of the leg ; and in others it is 
represented as encircling the limb tw T o or three inches above 
the malleolus (Fig. 221) ; but it is evident that these modes of dressing 
must defeat the great object which Dupuytren had in view, namely, the 
throwing out of the upper end of the lower fragment. 



Fig. 221. 




Dupuytren's 
splint incor- 
rectly applied. 



FRACTURES OF THE FIBULA. 



537 



When the limb is thus dressed, the knee may be flexed and the leg 
laid upon its outside, supported by a pillow, or upon its inside, as in the 
accompanying engraving (Fig. 222). 

If it is only a fracture of the external malleolus, or if the fracture has 
occurred in the middle or upper third of the bone, this treatment is no 
longer appropriate, and it will generally be found sufficient to place the 
limb at rest for a few days upon a suitable cushion or upon a pillow. 

Of late years I have not employed Dupuytren's splint, and especially 
because I have met with several examples of backward displacement of 
the foot following fractures of the fibula, which Dupuytren's splint is not 
competent to prevent or to remedy. This subject will be considered 

Fig. 222. 




Dupuytren's splint as originally applied by himself. 

more fully in connection with forward luxations of the tibia at its lower 
end ; but it is necessary to say here that this accident can be most cer- 
tainly avoided by employing the plaster-of-Paris or starch dressing ; 
taking care in applying the dressing to secure a thorough inversion of 
the toes and foot, the same as in case the limb were dressed with Dupuy- 
tren's splint. Care must be taken, also, not to press upon the limb much 
with the bandages above the malleolus externus. The same results may 
be attained, also, by a well-adjusted leather splint, or by two splints, 
which shall inclose the heel as well as the sides and front of the limb. 

It is scarcely necessary to say that, since after this accident anchy- 
losis is so frequent, early and unremitting attention should be given to 
the establishment of passive motion in the joint. Indeed, I cannot but 
think that a desire to accomplish the indications recognized and urged 
by Dupuytren has led to the neglect of the indication which ought to 
have been regarded as of equal, if not of the greatest, importance, 
namely, the prevention of contractions and adhesions around and be- 
tween the joint surfaces. 

I cannot too often call the attention of the surgeon to the danger of 
tight bandages, to which I have frequently made reference elsewhere ; 
and especially does it seem necessary here because I have recommended 
the use of the plaster-of-Paris bandage in this form of fracture, from 
which the greatest dangers are always to be apprehended, unless it is 
used carefully and skilfully. 

As a general rule, the dressings ought to be wholly laid aside by the 
end of the third or fourth week ; and although it may be well for a some- 
what longer time to keep the foot turned in, by having it properly sup- 
ported as it lies upon the pillow, yet after this date I regard the use of 
splints and bandages as only pernicious. 
35 



538 FRACTURES OF THE TIBIA AND FIBULA 



CHAPTEE XXXIII. 

FRACTURES OF THE TIBIA AND FIBULA. 

Causes. — A majority of these fractures are the results of direct blows 
or of crushing accidents, such as the kick of a horse, the passage of a 
loaded vehicle across the limb, the fall of heavy stones or timber, etc. 

In an analysis of two hundred and seventeen cases, where I could 
ascertain the cause, 1 have found the bones broken in the upper third 
from a direct cause seven times, and from an indirect cause three times. 
In the middle third fifty-two have been referred to a direct cause, and 
ten to an indirect ; and in the lower third fifty to a direct cause, and 
thirty- two to an indirect. An observation which does not sustain the 
remark of Malgaigne, based upon his analysis of sixty-seven cases, that 
fractures of the upper third are produced by direct causes alone, those 
of the middle third much more frequently by indirect causes, and that 
those of the lower third are especially due to indirect causes. 

Of the indirect causes, falls upon the feet from a considerable height — 
as from a scaffolding, or from the top of a building — are by far the most 
common. Eight times I have found the bones broken by muscular action 
alone, as in the following example : — 

Mrs. W., of Buffalo, aged about twenty-five years, and weighing at 
this time nearly two hundred pounds, was descending her door-steps with 
an infant in her arms, when, the steps being covered with ice, she slipped 
and fell, breaking her right leg just above the ankle. Mrs. W. says she 
felt and heard the bones snap before she touched the steps. Of this she 
is certain. 

We found the tibia broken obliquely, the fragments being quite mova- 
ble, but not much, if at all, displaced. The limb was dressed with a care- 
fully moulded and well-padded gutta-percha splint, and then laid in a 
pillow upon the bed. Mrs. W. experienced unusual pain from the frac- 
ture for several days, for the relief of which we were compelled at times 
to permit her to inhale chloroform. She was of a nervous temperament, 
and had frequently resorted to chloroform before to relieve neuralgic 
pains. The limb became very much swollen, and remained so for a 
week or two. No extension was ever employed. 

Within the usual time the bones united in perfect apposition, and in 
about four months she was able to walk without any halt. 

Pathology, Symptoms, etc. — We have seen that fractures of both bones 
through some part of the lower third are most frequent. Thus, of two 
hundred and seventeen fractures, twenty-two belonged to the upper third, 
seventy to the middle, and one hundred and twenty-five to the lower. In 
some cases the two bones were broken in different divisions. It is often 
difficult, and sometimes quite impossible, to determine precisely where 



FRACTURES OF THE TIBIA AND FIBULA. 539 

the fibula is broken ; but the analysis is sufficiently correct to illustrate the 
much greater frequency of fractures of the lower third, and also the fact 
that the two bones generally break nearly on the same level ; usually the 
point of fracture in the tibia is between two and three inches above the 
joint. 

In an examination of twenty museum specimens, I have found both 
bones broken at the same point, or within two or three inches of the same 
point, sixteen times, and at extreme points four times ; and in these last 
examples the tibia has always been broken in the lower third, while the 
fibula has been broken in the upper third. 

In twenty of the fractures mentioned as belonging to the lower third 
only the malleolus of the tibia was broken, while the fibula was broken 
two or three inches above its lower end. Some of these were compli- 
cated with dislocation of the ankle. 

I have seldom seen a transverse fracture of the tibia, except in its lower 
or upper extremity, in the expanded portions of the bone ; and even in 
those examples which we are accustomed to call transverse, because they 
are sufficiently so to prevent any sliding or overlapping of the fragments, 
there has existed, generally, a marked inclination of the line of fracture 
in one direction or another. 

The examples of fracture produced by muscular action have, without 
an exception, occurred in adults. Five of them were in the lower third 
of the leg, and three in the middle third. I think they were all of them 
nearly transverse, since they never became much, if at all, displaced. 

Most of the fractures of the tibia produced by falls upon the feet are 
very oblique, and the direction of the fracture is generally downwards, 
forwards, and inwards ; but I have found almost every conceivable varia- 
tion from this general rule. 

The fracture in the fibula is even more constantly oblique than the frac- 
ture in the tibia ; but this is a point of very little practical consequence, 
and one which we can seldom determine positively, unless one of the 
fractured ends protrudes through the flesh. 

Fig. 223. 



Compound and comminuted fracture of the leg. 



Compound and comminuted fractures are more frequent here than in 
any other of the bones of the body. My tables which have rejected all 
fractures demanding immediate amputation, most of which are compound, 



540 FRACTURES OF THE TTBIA AND FIBULA. 

do not for this reason give a just idea of their proportion to simple frac- 
tures, yet even in these tables, of two hundred and seventeen fractures, 
seventy-four were compound, and also, frequently, more or less commi- 
nuted. Of eighty cases reported by W. W. Morland, of Boston, from 
the Massachusetts General Hospital, and in which the character of the 
accident is recorded, thirty-nine were compound. 1 

The symptoms indicating a fracture of both bones of the leg are the 
same which are usually present in other fractures, namely, mobility, 
crepitus, shortening of the limb, distortion, swelling, etc. Generally, 
the lower end of the upper fragment projects in front, and can be seen 
or felt ; but in some instances the swelling follows so rapidly that it is 
impossible to feel distinctly the point of fracture, and its existence can 
only be determined by the crepitus, mobility, and shortening of the limb, 
or, perhaps, by the marked deformity or deviation from the natural axis. 

The shortening, where it exists at all, varies at the first from a line 
or two to a half or three-quarters of an inch. Generally, it is about 
half an inch. 

Dr. E. D. Merriam, of Conneaut, has reported to me a singular frac- 
ture of both bones of the leg, which occurred in his own person; the 
tibia being broken transversely near its upper end, and that portion of 
the fibula being also broken off to which the biceps is attached. The 
small fragment of the fibula became tilted outwards, and in this position 
it has remained permanently. 

Prognosis. — The average period of perfect union in twenty-nine cases, 
including those in which union was delayed by extraordinary causes 
beyond the usual time, was forty days. The general average, under 
ordinary circumstances, may be stated at about thirty days. 

Union has been noted as delayed a few weeks beyond the usual time 
in at least twelve cases of simple fracture. Cases of complete non-union 
are less frequent here than in the femur or humerus, the union taking 
place spontaneously often after the lapse of several months. We shall 
refer to this subject again when speaking of the treatment. 

F. C. T., of Erie Co., N. Y., set. 35, had an oblique, simple fracture 
of both bones, in the upper third, caused by jumping from a buggy, in 
June, 1852. 

The limb was dressed with lateral splints, compresses, and bandages, 
and laid upon a pillow. 

Eight weeks after the fracture had occurred, the gentlemen in attend- 
ance wished me to see the limb with them. I found Mr. T. still in bed, 
and the fragments not at all united. 

Mr. T. had enjoyed average health heretofore, but he was never very 
robust. When I was called to see him he looked pale ; his skin was 
cold and moist, pulse 120, and appetite poor. The broken leg and foot 
were greatly swollen. The swelling was oedematous. Considerable 
excoriations existed on the back of the leg. The fragments were quite 
movable, and were overlapped three-quarters of an inch. 

We agreed that the patient ought, as soon as possible, to be got out 

1 Transac. of Mass. Med. Soc. for 1840 ; Fractures, by A. L. Pierson. 



FKACTUBES OF THE TIBIA AND FIBULA. 541 

of bed, so .as to enable him to recover his strength, which had sadly de- 
clined. To this end, a gutta-percha splint was made to fit accurately 
the whole length of the leg ; and, having attached a large number of 
tapes, it was to be secured upon the limb. Several times each day it 
was to be removed, and the limb bathed with brandy and water. Grad- 
ually, also, the limb was to be brought down to the floor, and the patient 
be made to sit up, and, as soon as possible, he was to walk with crutches, 
or to ride. 

Nov. 4, 1852, Mr. T. visited me at my house. The directions had 
been followed implicitly. About two weeks after my visit he rode out, 
and in about nine weeks, or seventeen weeks from the time of the frac- 
ture, the bones were found united. His health and strength were quite 
restored, and the limb was no longer oedematous. It was found to be 
straight, or with only a slight projection of the upper fragment in front 
of the lower, and shortened three-quarters of an inch. 

In most oblique fractures of the shafts of these bones, union takes 
place with some shortening, the average being, even in simple fractures, 
about half an inch, but in some cases I have found the shortening one or 
even two inches. With judicious management, however, in simple frac- 
tures, this amount of shortening seldom or never occurs. 

Inasmuch, however, as among the claims lately instituted for the plas- 
ter-of-Paris dressing, it has been affirmed by at least one surgeon that 
it is competent to prevent in all cases shortening after fractures of the 
bones of the leg, as well as of the thigh (see chapter on General Prog- 
nosis), it may be necessary to refer the question at once to the test of 
experience, and thus dispose of it before considering the subject of treat- 
ment. 

Flori Albert, set. 24, fell, April 11, 1876, breaking his left leg three 
inches above the ankle, and was admitted to my service at Belle vue on 
the same day. My house surgeon, Dr. Thomas, while the limb was 
extended to its utmost, applied the plaster-of-Paris dressings from the 
toes to the knee. The dressings were removed, in my presence, at the 
end of six weeks, when the bones were found united with a shortening 
of one inch. 

Timothy Mahoney, aet. 30, fell and broke his left leg by a twist of 
his foot, February 21, 18T3. iVdmitted to Bellevue, ward 16. Fracture 
simple, oblique, and in lower third. Plaster-of-Paris was applied at once, 
while extension was made to the utmost. The splint was renewed once 
during the treatment, and on the 19th of April, the splint being removed, 
I found the limb united, and shortened three-quarters of an inch. 

These two cases will serve to illustrate what has been my experience 
at Bellevue and elsewhere with the plaster-of-Paris as a means of exten- 
sion. Of fifteen cases of oblique fractures of the shaft in my record, 
the average shortening is nearly three-quarters of an inch, and all are 
shortened. It is not the practice generally at Bellevue to give an anes- 
thetic in applying plaster to the leg, nor is it mentioned as having 
been used in more than one of the cases contained in Dr. Van Waga- 
nen's tables, referred to in the chapter on General Prognosis. But, to 
determine the value of this method in a case of simple oblique fracture 



542 FRACTURES OF THE TIBIA AND FIBULA. 

of both bones, I first measured the limb carefully before it was dressed, 
and found it shortened half an inch. The patient was then placed under 
the influence of an anaesthetic, and forcible extension made with pulleys 
until the limb was of the same length as the other. In this position it 
was retained until the plaster was applied, from the toes to above the 
knee, and had hardened. At the end of about six weeks the dressings 
were removed, and the limb was found to be shortened half an inch, pre- 
cisely the same as before the extension was employed. 

It is certain that this form of dressing makes no permanent extension 
within a range of three-quarters of an inch, and that, therefore, for all 
practical purposes, as a means of preventing shortening, it is useless. 

Generally, when a shortening has occurred, I have found the upper 
fragment in front of the lower, and oftener a little more upon the inner 
than upon the outer side. 

A deviation from the natural axis of the limb has been noticed by me 
in a good many instances. Several times the lower part of the limb has 
fallen backwards ; or, in consequence of its having rested too much upon 
the heel, it has inclined forwards ; and in other cases it has inclined 
inwards or outwards. 

Ulcers upon the back of the heel, seen by me many times, as a result 
of undue pressure upon this part, have, however, been presented but 
seldom in cases of simple fractures. 

It is not very unusual to find, also, over the exact point of fracture, 
and after the lapse of several months, or even years, an ulcer, or sinus, 
which is due sometimes to the presence of a small fragment of bone 
which has remained in the wound from the time of the accident, or to a 
thin scale which has subsequently exfoliated. In other cases it is due 
to the prominence of the salient angle when the lower part of the limb 
inclines considerably backwards ; and in still other cases,- no doubt, to 
the general dyscrasy of the system, and to the same causes which pro- 
duce chronic ulcers in the lower extremities where only the skin has 
been originally injured. I have reported elsewhere examples of this 
complication existing after five months, two and three years, 1 and in the 
remarkable case which I shall now briefly relate an ulcer existed at the 
end of twenty- three years. 

Thurstone Carpenter, when four years old, received an injury, break- 
ing both bones of one of his legs near its middle. The fracture was 
compound. It was dressed and treated by an excellent surgeon, then 
residing in Buffalo, but long since dead. 

Twenty-three years after the accident, Mr. Carpenter called upon me 
on account of a paralysis of his lower extremities, which had recently 
occurred. He stated that from the time of the fracture until within 
about one year an open ulcer had existed over the seat of fracture, and 
that soon after it had closed over completely he began to lose the use of 
his limbs. During the time it was open, small scales of bone have fre- 
quently been thrown off. The limb is half an inch shorter than the 
other, but straight. 

1 Trans. Amer. Med. Assoc. Report on Deformities after Fracture. 



FRACTURES OF THE TIBIA AND FIBULA. 543 

A gentleman residing in Quincy, Chautauque Co., X. Y., had his 
tibia and fibula broken near the ankle-joint in the year 1844, by the 
passage of a carriage-wheel across his limb. The skin was a good deal 
lacerated. The wounds, however, healed kindly, and the broken bones 
united in the usual time without any apparent deformity ; but the limb 
continued swollen and painful, until finally suppuration took place. 
After twelve years of great suffering, I amputated the leg near its middle, 
from which time he made a speedy recovery. I found the lower end of 
the tibia inflamed, softened, and expanded, and containing in its interior 
about three ounces of pus, but no sequestrum. 

Anchylosis of the knee or ankle-joint may follow as a result of the 
accident or of improper treatment ; and at one or both of these joints I 
have found more or less anchylosis at the end of nine months, one year, 
six years, twenty-five, thirty, and forty years. Generally, however, it 
disappears in a few weeks, and seldom remains to any considerable ex- 
tent in the knee-joint after the dressings have been removed two or three 
weeks ; but an Irishman called upon me in 1853, whose leg had been 
broken about three inches below the knee-joint six years before. It was 
a simple fracture. A surgeon in Ireland had treated the case. I found 
the limb shortened one inch and a half, the fragments being overlapped 
and displaced backwards at the point of fracture. The knee was also 
partly anchylosed. I could not learn what the treatment had been. 

In other cases, where no permanent anchylosis has followed, the 
ankle-joint has been occasionally painful, and subject to swellings, after 
the lapse of many years. 

In Muhlenberg's tables, already referred to in previous chapters, there 
are recorded 94 cases of delayed union or of non-union of these two 
bones at the same time ; also 84 similar cases where the tibia alone was 
ununited, and 2 in which the fibula alone was ununited : making a total 
of 180 cases. 

After all that has been said as to the occasionally serious nature of 
the consequences of these accidents, as shown in the shortening of the 
limbs, in their deviations from their natural axes, in the stiff ankles, 
ulcers, and abscesses, it must be still admitted that in another point of 
view these results are not extraordinary, and may hereafter continue to 
be fairly anticipated in a certain proportion of cases, even under the best 
management ; since it must be understood that more fractures of the leg 
are attended with serious complications than of any other limb ; and that 
while many produce death rapidly from the severity of the shock, and 
very many are condemned at once to amputation, a large number of 
those which are saved have been in that condition which has rendered 
the application of bandages or splints impossible for many days. Indeed, 
not a few of these crooked limbs may still be presented as real triumphs 
of the art of surgery, inasmuch as by consummate skill alone have they 
been saved. 

Treatment. — It is wholly impossible in a class of fractures which 
present so great a variety in regard to form, seat, and complications, to 
establish any universal system of practice : nevertheless it is possible to 
declare certain general principles in reference to a few well-recognized 
classes or varieties : and I shall deem it especially important to record 



544 FRACTURES OF THE TIBIA AND FIBULA. 

my disapproval of certain plans of treatment which have from time to 
time been suggested and adopted. 

It is seldom that I have found it necessary or useful to apply any 
bandages directly to the skin, whatever form of apparatus has been em- 
ployed ; but in certain cases of compound fractures, where dressings 
have been applied which needed support and protection, a bandage has 
been of service. The roller, unless the patient is a child, whose limb 
can be easily lifted and managed, is always objectionable; but the many- 
tailed bandage, made of narrow strips of cloth, laid upon each other, as 
we have already described in our general remarks upon bandages, etc., 
is occasionally useful. 

Having made these preparations, we proceed to flex the leg to a right 
angle with the thigh, and by the hands make extension and counter- 
extension as much as the patient will bear, or as much as may be neces- 
sary to restore the fragments to place, in case this restoration is found 
to be practicable. If the fracture is compound, and the point of bone 
protrudes through the skin, it is often difficult to replace it. That is, 
we are unable to overcome the action of the muscles sufficiently to make 
the limb of its natural length, and for this reason, mainly, we are unable 
to get the point of bone beneath the skin. If we cannot then " set" the 
bone, or bring the ends into apposition, and this will be the fact pretty 
often, we still have no apology generally for leaving the bone outside of 
the skin. First, an attempt must be made to accomplish this reduction 
by pulling aside the skin with the fingers, or with a blunt hook. This 
simple procedure has often succeeded with me in a moment, when others 
have been trying in vain to accomplish the same end by pulling upon 
the limb. If this fails, then the skin should be cut sufficiently to allow 
the bone to retire, or if the point is sharp, and especially if it is stripped 
of its periosteum, it may be sawn or cut oft*. Resecting thus the end of 
an oblique fragment does not generally affect in any degree the length 
of the limb, or interfere with a prompt and perfect cure, but, on the 
contrary, it often is advantageous in every point of view. In certain 
exceptional cases we may find it advantageous to employ an anaesthetic 
to aid us in the reduction. 

We are now prepared to apply the splints. Before, however, consid- 
ering the character and form of the splints to be applied, it seems proper 
to call attention again to the danger of ligation of the limb from the 
tightness of the bandages, and especially from the use of a bandage or 
roller placed beneath the splints and directly against the skin. 

The large size and irregular form of the bones of the leg, the small 
amount of muscular tissue covering them, especially near the articula- 
tions, the severity of the injuries to which they are liable, with their 
remoteness from the centre of circulation — these circumstances alto- 
gether, render them exceedingly exposed to injury from the too great or 
unequal pressure of splints or of bandages ; and it has often occurred to 
myself, as it has to l3r. Norris, whose remarks upon this point we have 
already quoted, to find the skin vesicated, or even ulcerated and slough- 
ing, when the patients are first admitted to the hospital ; a condition 
which, in nine cases out of ten, is due to the maladjustment of the 
splints, or to the tightness of the bandages. 



FRACTURES OF THE TIBIA AJSD FIBULA. 545 

If bandages are used under the splints, and next to the skin, they 
must be applied very moderately tight, and loosened or cut as the swell- 
ing augments ; and, from the first day of treatment to the last, the sur- 
geon must be careful to loosen or tighten the dressings when the swelling 
increases or subsides, just as the prudent boatman trims his sails to the 
rising and falling breeze. 

Dr. Krackowizer presented to the New York Pathological Society, 
June 10, 1863, a leg which he had amputated for gangrene occasioned 
by tight bandages. A boy, five years old, sustained an injury of the 
ankle-joint, which his medical attendant pronounced a fracture of the 
fibula, and for which he applied only a tight bandage. The child suffered 
a good deal after the bandage was applied, and the following morning 
the toes were blue, but the doctor paid no attention to this circumstance. 
The pain subsided on the third day, and on the fourth the bandages 
were removed, and the limb found to be gangrenous. 

The specimen showed that the fibula was not broken, but that there 
was a fissure or crack in the lower part of the shaft of the tibia. 1 

The following case, which has been communicated to me by Dr. Ful- 
ler, of Wyoming, N. Y., with permission to make such use of it as I 
saw fit, is sufficiently pertinent and deserves a public record: — 

A man, set. 71, fell from a tree, striking upon his foot, August 27, 
1855, producing a backward dislocation of both the tibia and fibula upon 
the astragalus, and also a fracture of both bones of the leg a few inches 
above the ankle. 

An empiric took charge of this unfortunate man, and immediately 
applied lateral splints and a firm roller from the toes to the knee. Not- 
withstanding the remonstrances and prayers of the patient to have the 
bandage loosened, it was kept on until the ninth day, when the doctor cut 
the bandage upon the top of the foot, and it was found vesicated. Ignor- 
ant, however, as to the cause of this vesication, and of the danger which 
it threatened, he omitted to loosen the remainder of the bandages, and 
the limb was left in this condition until the twenty-third day, when Dr. 
Fuller being called, and having removed all the dressings, found the in- 
teguments covering the whole foot dead and dried down to the bones. 
The dislocation had not been reduced. Soon after this the limb became 
oedematous, and on the 27th of October the leg was amputated by Dr. 
Barrett, of Le Roy, from which time the patient recovered rapidly. 

The fragments being adjusted, two lateral splints of leather, long 
enough to extend from near the knee-joint to the metatarsophalangeal 
articulations, and wide enough to nearly encircle the limb, are moulded 
to the limb on each side, and secured in place by successive turns of the 
roller. When the skin is delicate or tender, these should be underlaid 
with a thin sheet of cotton wadding or of sheet lint. A soft woollen 
cloth may answer the purpose equally well. A rack is then placed over 
the limb, such as will be seen figured for the suspension of the limb when 
dressed with plaster-of-Paris, and from this the leg is suspended. The 
objects to be attained by the suspension are threefold : first, to avoid the 

? Krackowizer, Amer. Med. Times, Nov. 7, 1863. 



54:6 FRACTURES OF THE TIBIA AND FIBULA. 

danger of pressure upon the heel, and consequent ulceration ; second, to 
prevent that driving down of the upper fragment upon the lower which 
constantly ensues when the foot rests upon the bed, or in a box which is 
immovable ; third, to obviate movement of the fragments upon each 
other when the patient sits up or lies down in bed. This movement, I 
observe, is peculiar. It is not simply a motion of the fragments upon 
each other, as upon a pivot at the point of fracture, which motion sel- 
dom interferes materially with consolidation, but it is a rising and falling 
of the upper fragment, or a motion to and from of the fragments, and 
also a riding motion ; either of which latter movements necessarily de- 
lays or defeats bony union. It is because these motions are generally 
permitted to occur in the usual modes of dressing these fractures, more 
than for any other reasons, that union is so often delayed in the case of 
these bones. In my own practice, when this plan of suspension is 
enforced, delay seldom occurs, but nothing is more common than for me 
to meet with it when other surgeons have had charge of the limb, and 
the suspension has been omitted. 

In suspending the limb, it is only necessary that the leg should float 
clear of the bed ; and I think it worth while to say that when lateral 
splints only are used, broad oval pieces of leather or of some other firm 
material should receive the limb in suspension, rather than narrow pieces 
of bandage, which soon become cords, and press unequally. To the 
sides of these oval pieces bands are attached, and their ends tied over 
the top of the rack. One must be placed under the knee and one under 
the ankle. 

If the fracture is above the middle of the leg, complete quietude of the 
fragments can only be obtained by carrying the splints and the bandages 
above the knee. 

I have already, in my remarks on the treatment of fractures in gen- 
eral, declared my acceptance of the so-called " immovable apparatus" 
in the treatment of certain fractures of the leg below the knee, and es- 
pecially of the plaster-of-Paris dressings. In hospital practice, where 
these dressings can be applied by experts, and where the limb can be 
watched daily and hourly, most or all of the dangers incident to this 
form of dressing may be avoided ; but even here I have occasionally seen, 
from a little too much delay in opening the dressings, serious trouble 
ensue. Its most devoted advocates, Seutin, Velpeau, and others, have 
never denied the necessity of caution in its use. To-day I hear of a 
surgeon in a neighboring State who has been prosecuted for damages in 
consequence of the death of the limb, caused, as is alleged, by this form 
of dressing. On the other hand, when applied judiciously, even imme- 
diately after the receipt of the injury, and when carefully watched and 
opened freely on the first notice of danger, it has, in my wards, and in 
the hands of my excellent house surgeons, often served its purpose more 
completely than any other apparatus or splints I have ever seen em- 
ployed. It has steadied and supported all parts of the limb more com- 
pletely, and permitted it to be handled more freely, than anything else 
could do. In simple fractures patients have been permitted to walk 
about upon crutches after the third or fourth day, and generally no harm 
has resulted. In one case, however, I believe this liberty caused a seri- 



FRACTURES OF THE TIBIA AND FIBULA. 547 

ous delay in the union ; and in another an abscess resulted, which would 
have been avoided if he had remained in bed. 

But it is in the management of compound fractures of the leg that I 
have of late seen the greatest advantage in this mode of dressing ; and 
it was in precisely these cases that I formerly believed the immovable 
apparatus most objectionable. I do not wish to retract anything I have 
heretofore said as to its dangers or as to its ability to make permanent 
extension, but I have not until lately fully appreciated to what a degree 
these dangers might be overcome by skill and attention. 

The following careful description of the proper mode of applying 
plaster-of-Paris bandages in fractures of the leg has been prepared at my 
request by Dr. S. B. St. John, late house surgeon to Bellevue Hospital. 
His large experience and his habits of accurate observation render his 
statements peculiarly trustworthy. 

" The materials necessary are, blanket, or cotton wadding, blanket 
being preferable, and plaster-of-Paris bandages, which are prepared by 
rubbing dry plaster into the meshes of a bandage of coarse texture, and 
rolling it up so as to make it convenient of application. (These may be 
kept ready for use in tin cans.) The bones having been placed in posi- 
tion, the. leg is placed upon the blanket, which is cut and folded neatly 
around it, and secured by a few pins. The blanket should extend from 
the base of the toes to the knee, or in case of fracture above the middle, 
or of compound fracture at any point, a few inches above the knee. The 
plaster bandages should then be immersed in hot water, to which a little 
salt has been added to hasten the setting, and while in the water they may 
be gently kneaded to insure moistening of every part. In about three 
minutes, or when bubbles of air cease to rise from them, they will be 
ready for use, and should be taken out as they are wanted, and gently 
squeezed to get rid of superfluous water. They are then to be applied 
after the fashion of an ordinary bandage, over the blanket, with just 
sufficient firmness to insure a complete fit. If, at any revolution of the 
bandage, the plaster is seen to be dry, it should be moistened by dipping 
the hand in water and rubbing it over the dry surface. Extra turns of 
the bandage should be taken at the places where it is necessary to secure 
extra strength to the splint. Three or four bandages (six yards long) 
are usually sufficient to make a firm splint. The splint will usually be 
sufficiently pliable just after its application to allow of rectification of any 
faulty position which may have occurred during its application. It should 
then be kept in shape by the pressure of the hands until it hardens, which 
will be in from ten to thirty minutes, according to the freshness of the 
plaster and texture of the bandages used. If, for any reason, it is de- 
sirable to cut the splint so as to admit of its removal, or to cut a fenestra 
through which to observe any part, this may best be clone before the 
plaster becomes perfectly dry, say in from two to five hours after its ap- 
plication, depending upon the quality and freshness of the plaster. It 
will then cut like hard cheese, and a stout sharp knife should be used. 
In splitting a splint anteriorly, it is convenient at the same time to take 
out a piece about an inch wide, by making two parallel cuts one inch 
apart, one on either side of the median line, extending nearly through 
to the blanket, and then by raising the strip at the upper edge, and cut- 



548 



FRACTURES OF THE TIBIA AND FIBULA 



ting on either side alternately, the section may be completed, and the 
central slip removed without danger of cutting through the blanket and 
wounding the patient. The blanket may then be cut with scissors and 
the splint sprung- off to examine the limb, if necessary. When replaced, 
a bandage should be applied over it. If it should be necessary to cut a 
splint which has already become dry, and cuts with great difficulty, it 
may be softened with hot water, applied by a sponge in the track of the 
proposed section for ten or fifteen minutes. 

" If it is necessary to cut such a large fenestra that only a small strip 
of the splint would be left connecting its upper and lower portions, it 
is better to adopt a different plan of application. For this it is neces- 
sary to have a solution of plaster-of-Paris in water of the consistency 
of cream. A piece of blanket is then cut long enough to reach from 
the toes to the top of the proposed splint, and about fifteen inches wide. 
This is to be thoroughly soaked in the solution, and folded several times 
so as to be about two or three inches wide when folded. This is to be 
applied along that part of the limb which it is not necessary to keep 
under observation (if convenient, along its posterior aspect), and it is 
then to be secured in position by circular turns of the plaster bandage 
above and below the portion to be left exposed. Whenever a plaster 
apparatus extends above the knee, and it is proposed to sling the leg 
from a cradle, the leg should be flexed slightly upon the thigh, so that 
it may be swung horizontally. Any portion of a plaster splint exposed 
to the moisture of discharges or of water used in dressing should be 
carefully protected by oil silk and cotton wadding. 

" In cases where not much swelling is anticipated, blanket is prefer- 
able to cotton wadding, as an elastic medium between the splint and 
skin, because it is of more even thickness and retains its place better 
when the splint is removed, but cotton answers better w T hen much swell- 
ing is anticipated, as being more elastic." 

Fig. 224. 




Plaster-of-Paris dressing, and suspension. 



The accompanying illustration (Fig. 224) has also been made for me by 
Dr. St. John, and furnishes a faithful picture of one of the many similar 
cases which have been under treatment by this method at Bellevue 
Hospital. 

Dr. George A. Van Wagenen, while acting as house surgeon at 
Bellevue, devised a most ingenious, simple, and effective apparatus for 



FRACTURES OF THE TIBIA AND FIBULA 



549 



suspending the limb, which will be found illustrated in the accompanying 
woodcut (Fig. 225). 

" It consists of an elbow "| of wood projecting over the foot of the 
bed, from which the leg is suspended by two pieces of rubber tubing ; 
one above the ankle, the other just below the knee. The tubes have 
common grooved iron pulleys or wheels at each end : those above, roll- 
ing on a large iron wire to allow motion toward the head or foot of the 
bed ; those below, at right angles to the others, holding the rings of rope 
in which the leg rotates ; this last being far the most important, allowing 
the patient to turn on either side. Motion on these rollers is accomplished 
with so little resistance that there is no pain. 



Fig. 225. 




Van Wagenen's suspension apparatus. 

" The upright of the elbow to go at the foot of the bed should be 
long enough to rest on the floor, or any convenient part of the bedstead, 
and project about two feet above the level of the mattress, — the hori- 
zontal piece long enough to reach nearly to the knee ; pine f by 2 inches 
is heavy enough. The angle made by these pieces is braced, and a 
strap of hoop-iron outside makes it very strong. In the horizontal 
piece two slots are cut wide enough to allow the iron pulleys to pass 
through, and of sufficient length to allow the patient to draw himself up 
and down in bed. A \ inch iron wire passes the whole length of this 
piece above the slots, steadied by small staples, so that it may be with- 
drawn. On this the upper pulleys run. The wire shields I 1 above 

these slots are to prevent the bedclothes from resting upon the rollers. 

" The pulleys or wheels are fastened in the rubber tubes by making 
a few turns of copper wire around the iron screw of the pulley. This 
is pushed into the tube and bound outside with fine wire. 

" Rings of rope large enough to pass over the foot are then put 
through the lower pulleys. If these rings open, or the foot is slipped 
out of them, the leg is taken down without any of the apparatus about 
it, and the large wire may be withdrawn and the leg lowered, with the 
pulleys and rings still attached." 1 



1 Van Wagenen, Med. Record, April 1, 1873. 



550 



FRACTURES OF THE TIBIA AND FIBULA. 



There are a few cases in which a very much better position of the 
fragments can be secured by placing the patient under the influence of 
an anaesthetic, and by applying the dressings during complete anaesthe- 
sia. But the surgeon needs to be warned of two things in this connec- 
tion : first, that just as much harm can be done to the soft parts by 
violent wrenching and pushing when the patient is insensible as when he 
is fully conscious ; second, that while the patient is passing under the 
influence of an anaesthetic he is liable to violent muscular spasms, which 
may do serious injury. 

Dr. Banga, of Chicago, prefers stilts to suspension, as a means of 
support for his plaster splint. His method is a modification of a plan 
adopted by Ries, of Basle ; but it does not seem to me to possess any 
advantages over suspension. 1 

What is known as the Bavarian method of using plaster-of-Paris has 
been adopted by some American surgeons, which consists essentially in 
leaving the splint open in front and behind, or in leaving it connected 
posteriorly only by a strip of cloth, which serves as a hinge. This plan 
has been especially recommended by Prof. James L. Little, of this city, 
by Prof. W. W. Dawson, of Cincinnati, 2 and by Dr. (x. Wacherhagen, 

Fig. 226. 




G. Waclierhagen's method. 

of Brooklyn, N. Y. By this method all danger of strangulation is 
avoided. As between this plan and the use of sole leather, which can 
be made to fit as accurately, or nearly so, as plaster-of-Paris, it is, 
therefore, a question of convenience rather than of practical utility. 

In such few cases as demand or warrant a resort to permanent exten- 
sion and counter-extension, a double-inclined plane furnishes a conve- 



1 Banga, Chicago Med. Journ. and Examiner, June, 1877. 

2 Wacherhagen, Hosp. Gazette, May 24, 1879. 



FRACTUEES OF THE TIBIA AND FIBULA 



551 



nient mode for its accomplishment ; but it is only occasionally that, in 
fractures of the leg, permanent extension and counter-extension can be 
employed; an assertion which, however much it may surprise the inex- 
perienced, observation will prove to be true. If the fracture is near 
the middle of the leg, quite remote from the points upon which the ap- 
pliances for extension, etc., are to be made fast, and the inflammation is 
moderate, something may be done in this way; but when the point of 
fracture approaches the ankle-joint, as it actually does in a great ma- 
jority of cases, a gaiter, made of any material whatever, if it has suffi- 
cient firmness to overcome completely the action of the muscles, will 
inevitably cause congestion and swelling, accompanied sooner or later 
with great pain and with ulcerations, and simply because the extension 
is made directly upon parts already tender and inflamed from the acci- 
dent itself : and when we add to this complete and violent ligation of 
the limb near the seat of fracture, a similar ligation of the limb just 
below the knee, for the purpose of making counter-extension, as is done 
in what is known among American surgeons as " Hutchinson's splint," 1 

Fig. 227. 








James Hutchinson's splint, for extension, etc., in fractures of the leg. (From Gibson.) 

we are prepared to understand how the worst consequences may ensue. 
I have once seen, when this abominable apparatus had been used, a 
complete ring of ulceration below the knee, and another as complete 
around the foot and ankle. The limb was twice girdled, and yet the 
surgeon thought he was performing a duty for the omission of which he 
would scarcely have been regarded as excusable. 

Jarvis's adjuster, a still more mischievous, inasmuch as it is a more 
powerful instrument, operating in a similar manner, has been productive 
of like consequences; but Jarvis's adjuster is liable to the additional 
objection that by its great weight it drags off the limb, turning the toes 
outwards, an objection which no care or diligence can generally over- 
come. 

I could wish that neither of these appliances would ever again be 
impressed into the service of broken legs. 



1 Elements of Surgery, by John Syng Dorsey, vol. i. p. 181. Philadelphia, 1813. 



552 



FRACTURES OF THE TIBIA AND FIBULA. 



Neill, of Philadelphia, and others have sought to overcome some of 
the difficulties in the way of making extension in fractures of the legs, 
by substituting adhesive plaster for the usual extending or counter- 
extendins: bands. . 



Fig. 228. 




John Weill's apparatus for fractures of the leg requiring extension and counter-extension. 

Says Dr. Neill: "For simple fractures of both bones of the leg, 
attended with shortening and deformity not easily overcome, the limb 
should be placed in a long fracture-box with sides extending as high as 
the middle of the thigh, and a pillow should be used for compresses. 

" The counter-extension is made by strips of adhesive plaster, one 
inch and a half in breadth, secured on each side of the leg below the 

Fig. 229. 




John Weill's apparatus for compound fractures of the leg. 

knee, and above the seat of fracture by narrower strips of plaster 
applied circularly. The end of the counter-extending strips may then 
be secured to holes in the upper end of the sides of the fracture-box, by 
which the line of the counter- extension is rendered nearly parallel with 
the limb. 

"'The extension is also to be made by adhesive strips, in a mode 
which is now well known and understood. The ends of the extending 
bands may be fastened to the footboard of the box." 1 

Dr. Neill further remarks : " In compound fractures of the leg, short- 
ening and deformity are often difficult to overcome, as is well known to 
experienced surgeons. In such cases we may wish to dress the wounded 
soft parts, and, at the same time, maintain a certain amount of extension 
and counter-extension. 

" This can be readily accomplished by having the sides of the frac- 
ture-box sawed in two parts at the knee, so that the sides of the box 
above the knee, from the upper ends of which the counter-extension is 



Philadelphia Med. Exam., vol. xi. p. 580, 1855. 



FRACTURES OF THE TIBIA AND FIBULA 



553 



made, need not be disturbed during the dressing, while that portion of 
the side of the box corresponding to the leg may be opened at pleasure, 
without diminishing the tension of the extending or counter-extending 
bands." 

In compound fractures of the leg, Dr. Gilbert recommends a modifica- 
tion of the common fracture-box. In this apparatus the foot-board is 
omitted, and a block for the reception of the frame of the tourniquet is 
substituted. Each side of the box consists of three separate segments. 

Fig. 230. 




Gilbert's box for compound fracture of the leg. 
1. The four counter-extending adhesive strips, as if encircling the knee and upper part of leg. 2. 
The two extending adhesive strips crossing at the bottom of the foot, ready to be applied to the foot. 
3. Tourniquet. 

Of these the upper and lower are permanently screwed to the bottom- 
board, and the central one is attached by hinges. By this arrangement 
there is full access to the wound, which may be dressed from day to clay 
without disturbing the extension and counter-extension, maintained by 
the permanently attached upper and lower segments. 

The following woodcuts are intended to illustrate an apparatus invented 
by R. 0. Crandall, for the purpose of making permanent extension. The 

Fig. 231. 




Section of Crandall's apparatus, applied to the limb ; showing adhesive plaster counter-extending 
bands and gaiter for extension, etc. 

extension is represented as being made by a gaiter, but Dr. Crandall 
leaves it to the choice of the surgeon whether he shall employ the gaiter 
or adhesive strips. 1 

Without intending to deny to these contrivances for permanent exten- 
sion much ingenuity and some little practical value, I am far from con- 
ceding that they will be found capable of overcoming the action of the 



1 Crandall, Phil. Med. Journ., vol. iv. p. 193, Jan. 1856; also Transac. of Med. 
Assoc, of Southern and Central New York, 1S55, pp. 81, 82. 



36 



554 



FRACTURES OF THE TIBIA AND FIBULA 



muscles where the ends of the fragments do not support each other. 
Their mode of action is such that they can scarcely do more than to 
steady the limb, and if they operate upon the fragments at all in the 
direction of their axes, it must be only in the most inconsiderable degree. 



Fig. 232. 




Or; 



idall's apparatus complete. The counter-extending straps are passed over a block of wood, 
supported above tbe knee, to prevent their pressure upon the sides of the knee. 



The adhesive plasters are substituted for the circular knee-bands and the 
gaiters, with a view to avoid ligation ; but in order to do this they must 
not encircle the limb, but only be laid parallel to its long axis. The leg 
of an adult, or that portion to which the adhesive plasters can be applied, 



Fig. 233. 




Posterior view of the lower portion of Crandall's apparatus. 



supposing the fracture to be exactly at the centre, may be sixteen inches, 
that is, eight inches for extension and eight for counter-extension ; but 
when we employ the same means for extension in fractures of the thigh, 
we find it necessary to apply the strips over the whole of these sixteen 
inches, the entire length of the leg, or they will not hold. It will be 
apparent also that we cannot use even the eight inches which we have, 
for the purpose of argument, allowed these gentlemen in fractures of the 
leg. There must be at least a space of eight inches between the ends of 
the two opposing strips in order that they may operate at all upon the 
fragments ; indeed, I do not believe that even then their influence would 
reach beyond the skin to which they were directly applied ; but if a 
space of eight inches is left, only four remain for the strips at either 
end ; and this is an amount of surface wholly insufficient for our purpose. 
What, then, shall we do when the fracture is near one of the extremities 
of the bone ? These gentlemen seem to have forgotten, moreover, that 
the whole leg is tender, and that the skin easily vesicates. In short, 
they have not seen the many points of difference between the application 
of these means in fractures of the thigh and leg, and which, while they 
allow us to accomplish all that we could desire with the one, are of little 
or no use in the other. We shall then always come to the same conclu- 



FRACTURES OF THE TIBIA AND FIBULA. 



555 



sion ; whatever means we may employ to make permanent extension in 
fractures of the leg, we must either fail to accomplish all that we desire, 
or incur the hazards incident to complete and firm ligation of the limb ; 
and if the preference is given to any form of apparatus to accomplish 
these ends, it must be to some form of the double-inclined plane, by which 
we may at least avoid ligation in the upper part of the limb, the counter- 
extension being made against the under surface of the thigh while it is 
resting upon the thigh-piece; or to one of the long straight thigh-splints, 
which will enable us to make the counter-extension from the thigh and 
perineum. 

If a double-inclined plane is used, I prefer either a plain apparatus, such 
as we have already described as in use for fractures of the thigh, con- 
structed of boards, joined together by hinges opposite the knee, and with 
an upright foot-board, upon which a carefully arranged and thick cushion 
has been placed ; or the more elegant double-inclined plane of Liston. 

Fig. 234. 




Liston's double-inclined plane ; applied to the leg in a case of compound fracture. (Prom Miller.) 



In using Liston's apparatus, it must not be inferred that the knee is 
always to be bent. The apparatus is designed to be used occasionally 



Fig. 235. 




Louis Bauer's wire splints for the leg. 1 



as a straight splint ; and there will be found many cases of fractures of 
the legs in which the straight position will be most suitable : this is espe- 



Bauer, Buffalo Medical Journal, April, 1857, vol. xii. 



556 



FRACTURES OF THE TIBIA AND FIBULA 



cially true of such fractures as, occurring just below the knee-joint, have 
the line of fracture directed obliquely downwards and forwards. But 
there are many compound fractures which demand the same extended 
position ; and in nearly all cases where this form of apparatus is used as 
a double-inclined plane, the lower end of the splint should be elevated 
so that the heel shall not be much below the level of the knee. 



Fig. 236. 




Swing box or " cradle." (From Skey.) 



Bauer's wire splints, used also for side-splints, when they are formed 
to fit the limb accurately, possess some advantages which must recom- 
mend them to the attention of surgeons ; but neither these splints nor 
any others, however accurately fitted, ought to be applied directly to 
the naked skin. They require always the interposition of a well-padded 



lining. 



Fig. 237. 




Salter's cradle. (From Fergusson.) 



Boxes are rarely useful except in certain compound fractures. They 
are heavy and awkward machines, which prevent the patient from moving 
readily in bed ; or which, being fixed, if he does move, allow the upper 



FRACTURES OF THE TIBIA AND FIBULA 



557 



fragment only to descend, or to move upon the lower as a fixed point. 
If used at all, they ought generally to be suspended, or made to move 
on a suspended railway. But however they are arranged, the limb is a 
great part of the time concealed from sight, and the surgeon is prevented 
from making use of such means to rectify deviations in the line of the 
bone as he would probably have otherwise employed. 

The swing invented by James Salter, of London, is constructed so as 
to allow not only a lateral motion, but also a more complete motion in 
the direction of the axis of the limb, by which the danger of pushing the 
fragments upon each other is obviated. This is accomplished by the 
rolling of two pulley-wheels upon a horizontal bar. The case in which 
the leg rests may be made of metal or of wood, and the frame of iron, 
for the sake of lightness and strength. 

Dr. Hodgen, of St. Louis, suspends the box over a pulley placed 
transversely, so that by drawing the rope to the right or to the left, the 
box may be turned upon either side. 

The suspension apparatus devised by Dr. John W. Trader, of Sedalia, 
Missouri, for the treatment of 

compound fractures of the F ICt - 238. 

leg, when it is desired to em- 
ploy irrigation, I have found 
very useful in my wards at 
Belle vue. The limb is sus- 
pended by transverse strips 
of cloth, over a tray, from 
which the water is conducted 
by nozzles. I have found it 
convenient to attach India- 
rubber tubing to these noz- 
zles, through which the water 
may be conveyed to a pail 
placed beside the bed. We have used it satisfactorily, also, for other 
cases than fractures. 

Fracture-boxes, employed in the treatment of compound fractures of 
the leg, are, in this country, sometimes filled with bran ; the bran being 
closely packed upon all sides so as to support the limb uniformly and 
gently. This method of treating compound fractures of the leg was first 
suggested by J. Rhea Barton, of Phi- 
ladelphia, 1 and has been much used in 
the Pennsylvania Hospital ; and more 
lately it has been introduced into the 
Bellevue and New York City Hospi- 
tals. It possesses the advantage of 
affording a perfect protection against 
flies in the summer season, and of ab- 
sorbing the matter as it escapes. 

In using the " bran-box," the sides 
are first brought up into position and 




John W. Trader's suspension apparatus for compound 
fractures. 




Fig. 239. 



'■^^T^TT^Tr'T::^!^ 




Fracture-box, with movable sides. 



1 Barton, Aruer. Journ. of Med. Sci., vol. xvi. p. 31, and vol. xix., p. 515. 



558 



FRACTURES OF THE TIBIA AND FIBULA. 



made fast. A piece of muslin cloth, one yard in length by half a yard 
in breadth, is then laid upon the box, and into this the bran is poured, 
until it is about one-fourth full. The bran is then distributed so as to 
fit the back of the leg, and the limb is placed in position. After which, 
additional bran is packed on either side of the limb, until it is nearly or 
quite enveloped ; the wounds being first covered by pieces of lint smeared 
with simple cerate. Finally, the upper portion of the muslin sack is 
fastened around the limb just above the knee, to prevent the escape of 
the bran. 

Whenever any portion of it becomes soiled by blood or pus, it may be 
dipped out with a spoon, and its place supplied with fresh bran. The 
support which it gives to the limb is also uniform without being at any 
time excessive ; and Dr. Coates states that the escape of blood in rapid 
hemorrhages has been known to increase the bulk of the bran sufficiently 
to arrest the bleeding by its accumulated pressure. 

Dr. L. D. Mason, of Brooklyn, N. Y., has carbolized the bran, by 
stirring in a small quantity of carbolic acid. 1 

In whatever position the leg is placed, and with many of the forms of 
apparatus which we have enumerated, it will be found necessary to pro- 
tect the limb from the weight of the bedclothes 
by some contrivance similar to that figured in 
the accompanying drawing ; or by a rack, such 
as is represented for suspending the leg when 
leather splints or the immovable apparatus is 
employed. 

Malgaigne, who declares that every surgeon 
knows how impossible it is, in an immense ma- 
jority of cases, to overcome the projection of 
the superior fragment when the limb is placed in the extended position 
(over .a double-inclined plane), and who aifirms that neither Pott's posi- 
tion, nor Dupuytren's modification of it, will do much if any better, nor, 



Fig. 240. 




Wire rack for fracture of leg. 



♦ 



Fig. 241. 




Malgaigne's apparatus for oblique fractures of the leg. (From Malgaigue.) 

indeed, that Laugier's plan of cutting the tendo Achillis possesses in this 
respect any real advantage, concludes at last to resort to a new and really 
ingenious method, the value of which, also, he claims to have already 
fully demonstrated. His apparatus consists simply of a steel band of 
sufficient size to encircle three-fourths of the limb, at the two extremities 



1 Mason, N. Y. Med. Journ., Sept. 1876, p. 253. 



FKACTURES OF THE TIBIA AND FIBULA 



559 



of which are two horizontal mortises through which a band is passed, 
and which may be buckled upon itself behind. The centre of the me- 
tallic arch, in front, is penetrated with a firm metallic screw, terminating 
in a very sharp point, and which is moved by a flat thumb-piece. 

The limb being laid over a double-inclined plane, and the pads being 
carefully adjusted, as we have already directed when speaking of other 
forms of apparatus, and the limb properly extended, the apparatus of 
Malgaigne is placed over the limb, with the sharp point of the screw 
resting upon the upper fragment, a few lines above the point of fracture ; 
and at the same moment that this point is pressed firmly down to the 
bone, the fragments being held together by an assistant, the strap is 
buckled as tightly as possible under the splint. A few turns of the 

Fig. 242. 




Malgaigne's apparatus applied. (From Malgaigne.) 

screw will now make its point penetrate more deeply into the bone, and 
insure the most complete apposition of the broken extremities. " This 
is accomplished," says Malgaigne, "with very little pain to the patient;" 
and, as will be seen, the steel arch effectually prevents any ligation of the 
limb. I cannot say that the plan receives my unqualified approval; yet 
I have employed it to advantage in some cases of old ununited fractures. 
Treatment of Delayed or Non-union. — It has already been remarked 
that pretty frequently in this fracture union is delayed considerably 
beyond the usual period of six or eight weeks, but that in a large major- 
ity of these cases of delayed union consolidation is finally accomplished 
without any surgical operation. This is most often effected by permit- 
ting the patient to rise and go about on crutches, the fragments being 
supported by some light but firm splint, which will permit also the limb 
to be opened daily and washed or rubbed gently, so as to restore its cir- 
culation. In some few cases, after the lapse of several months, if this 
method has not succeeded, the bones have been known to unite firmly in 
a year or two, without side splints, and even when the patient has been 
bearing his weight upon the limb. But such a result is rare, and is 
scarcely to be expected. If, indeed, the union is not effected within four 
or five months with the splints and crutches, it is better to resort at once 
to perforation between the fragments, as has been directed in the general 
chapter on Delayed or Non-union of the Bones. 



560 FRACTURES OF THE TIBIA AND FIBULA. 

A few illustrative examples will serve, perhaps, to enforce these state- 
ments. 

John Connor, set. 28, was admitted to Belle vue Hospital, Oct. 31, 
1869, with a simple fracture of his leg below its middle. The limb was 
placed in a fracture-box, but not suspended, where it remained six weeks. 
A starch bandage was then applied, and continued two months. About 
the middle of February the fragments were perforated, and the starch 
bandage again applied. March 3d, the patient having come under my 
care, I substituted leather splints for the starch, and directed him to go 
about on crutches. April 2d, finding that union had not taken place, I 
perforated the fragments thoroughly, applied the splints, and allowed 
him again to use his crutches. A few months later 1 was informed that 
bony union had taken place. 

Mary Welsh, aet. 28, was admitted to Bellevue w T ith a simple fracture 
of the leg near the upper end of the lower third. Within one week it 
was inclosed in a plaster-of-Paris dressing. At five weeks there was no 
union. The plaster splint was renewed, and she was allowed to go about 
on crutches. No bony union at ten weeks. Splints and bandages were 
then removed, and she continued to walk with crutches, and in one month 
the union was firm. 

Cornelius Hasbrook, aet. 36, had his left leg broken by a direct blow- 
June 16, 1877 — fracture comminuted. A surgeon placed the limb in a 
" bran box" until the swelling had subsided, and then applied a plaster- 
of-Paris dressing, which was removed in four weeks. The fibula had 
united, but not the tibia. The splint was kept on, and he w T as allowed 
to go upon crutches. He consulted me eight months after the accident. 
I found the limb much wasted, and no bony union of the tibia. He was 
advised to lay aside his crutches and to remove the splints, and to walk 
about. This advice w r as followed by his surgeon, Dr. Herrich, of Passaic, 
except that he was permitted occasionally to use crutches. In about four 
months the union was firm, the limb being a little bent outwards at the 
seat of fracture, and shortened three-quarters of an inch. 

The following is the only case I can recall in which I have found these 
bones ununited at the end of a period so long as four years : — 

A gentleman, aet. 33, from Bergen, N. Y., was struck by a billet of 
wood on the 3d of August, 1856, breaking his left leg just below the 
knee. The fracture of the tibia was transverse. His surgeon dressed 
the limb on a double-inclined plane. Four years later he consulted me, 
when I found the bones still ununited, although he was in perfect health, 
and had been constantly using the limb. I advised perforation, but he 
did not consent, and I have never heard from him since. 

In Dr. Muhlenberg's tables of delayed union and ununited fractures, 
in a total of 91 examples involving both bones, 71 were finally cured, 3 
were relieved, 19 failed, and 1 died. It might be more proper to say 
71 were cured, and 23 failed. 

Of these, 10 were cured by friction, 26 by mechanical appliances and 
immobilization, 1 by seton, 20 by resection, and 10 by drilling. 1 died 
after resection. 1 

1 Muhlenberg, Agnew's Surg., vol. i. p. 806. 



FRACTURES OF THE TIBIA AND FIBULA. 561 

Resection and Refracture of Crooked Legs. — In some cases of extreme 
deformity of the legs consequent upon badly united fractures, resection 
of the bones has been practised with more or less success. 

A case of resection is reported by Charles Parry, of Indianapolis, 
Ind. A young man, ast. 15, having broken his leg near its middle, the 
fragments united, from some cause, nearly at right angles with each other. 
Some years afterwards, on the 15th day of January, 1838, Dr. Parry 
operated, by removing a wedge-shaped portion from both the tibia and 
fibula. The recovery was tedious, but satisfactory. 1 

Mr. Key, of London, made an operation of this kind upon a gentle- 
man who had suffered a fracture of the right tibia from a musket ball. 
The limb was nearly useless, since he could only bring his toes to the 
ground. Mr. Key operated in October, 1838, and when the report of 
the case was made, five months subsequently, the patient was doing well. 2 

In September, 1840, Dr. Mutter, of Philadelphia, made a similar 
operation upon a patient, whose leg was shortened three inches and a 
half, and very much deformed ; by which operation, when the recovery 
was complete, the shortening was considerably reduced. 3 

More often cases are presented of badly united fractures of the leg, 
which seem to justify a resort to refracture ; and, while this procedure 
is attended with little or no danger to life, after neither resection nor 
refracture can we always make sure of a reunion. If, moreover, the 
surgeon expects, by a refracture, to lengthen a limb much, where it is 
merely overlapped and shortened, he is, I am certain, destined to disap- 
pointment, at least in all cases where sufficient time has elapsed for the 
bones to have become firmly united. I have myself several times re- 
fractured bones ; and I have several times met with cases of old fractures 
newly broken ; and I have constantly observed that I could never, in the 
end, make them but very little if any longer than they were before the 
refracture. The muscles had contracted and shortened, and their con- 
traction could not be overcome. In the case reported by Mutter, he 
believed that he stretched the muscles two inches. With all deference 
for the skill and honesty of this gentleman, I think that he was mistaken. 

If, however, the object of the refracture is to straighten the limb, then 
no doubt it may be sometimes accomplished ; and in some degree also 
by the straightening of the limb the shortening may be overcome ; but, 
in our opinion, such procedures ought to be reserved for extraordinary 
circumstances, unless the refracture can be made soon after the union 
has taken place. In those cases in which I have refractured the tibia 
and fibula after a recent union, the bones have reunited promptly. 

An instructive case of refracture is reported by Dr. Horner, of Phila- 
delphia, in the Medical Examiner. The limb had been broken eight 
weeks, and was quite crooked, but was not very firmly united, and Dr. 



1 Parry, Amer. Journ. Med. ScL, August, 1839, p. 334. 

2 Key, Amer. Journ. Med. ScL, Aug. 1839, p. 339 ; from Guy's Hospital Reports, 
April, 1839. 

3 Mutter, Amer. Journ. Med. ScL, April, 1842, p. 359. Three similar cases may 
also be found in the Oct. No. for 1841, and the April No. for 1842 of the same journal, 
in which the operations were made by Portal, of Palermo. Malgaigne mentions two 
other examples. 



562 FRACTURES OF THE TARSAL BONES. 

Horner, having refractured it, was able at once to restore it to a nearly 
straight line. 1 

Mary McCormick, set. 5, 342 E. Twenty -third Street, broke her left 
leg near the upper end of the lower third. A doctor was called who 
did not recognize the fracture. Probably it was a green-stick fracture, 
and no splints were applied. Six months later she was taken to another 
excellent surgeon in this city, who found it greatly bent at the seat of 
fracture, and he refractured it. The child remained a long time in bed 
with splints, and when I was consulted in 1868, about eighteen months 
after the refracture, no bony union had taken place. 

T. B. Johns, of Terre Haute, Indiana, had his right leg broken near 
its middle. Under the care of Prof. John E. Link, of the same place, 
it united. In Nov. 1876, ten years after the first accident, he was thrown 
from a horse, and it was refractured at the same point, after which the 
tibia refused to unite. Six months later he consulted me, and I advised 
perforation at the seat of fracture. I am informed that Dr. Pancoast, 
of Philadelphia, subsequently brought about union by perforation, but 
that extensive suppuration ensued, and that the cure was not accom- 
plished in less than six months. 

In the case of Blair, related in connection with fractures of the tibia, 
and which was finally treated successfully by me by perforation, the 
fragments united after the original accident, and were refractured at the 
end of six weeks by an attempt to overcome an anchylosis at the knee- 
joint. They refused thereafter to unite until placed under my charge. 



CHAPTEE XXXIY. 

FRACTURES OF THE TARSAL BONES. 

Causes. — The astragalus is generally broken by a fall from a height, 
the patient having struck upon the bottom of the foot. Monahan, in an 
analysis of ten cases, found it had been broken by a fall upon the foot 
nine times, 2 and only once by a crushing accident. 

The calcaneum is also occasionally broken by violent lateral pressure, 
but much more often by a fall upon the foot, or rather upon the heel. 
In some instances both heel-bones have been broken at the same moment; 
but Malgaigne has collected eight cases of fracture of this bone by mus- 
cular action, as in jumping upon the toes, the posterior portion of the 
bone being thus violently acted upon by the tendo Achillis. South, in 
his Notes to Chelius, has mentioned two other cases, one of which was 
seen by Lawrence, and has been reported in the second volume of the 

1 Horner, New York Journ. Med., May, 1851, p. 432. 

2 Fracture of the astragalus, with analysis of the recorded cases of this injury. 
An inaugural thesis, presented to the faculty of the Buffalo Med. Col., March, 1858, 
by Bernard Monahan, M.D. 



FRACTURES OF THE TARSAL BOXES. 563 

Lancet. This person had received the injury by jumping off a stage- 
coach. The fragment was found to be drawn upwards slightly, but not 
so far as to prevent crepitus when the muscles on the back of the leg 
were relaxed. The other example mentioned by South is a cabinet 
specimen contained in the museum of St. Bartholomew's Hospital. The 
fracture had taken place just below the attachment of the tendo Achillis, 
but the upper fragment was not displaced. 1 Mr. Cooper mentions two 
other cases, both produced by violent efforts on the part of the patients 
to sustain themselves when falling. In one of these the fragment was 
immediately drawn up three inches. 2 

The other bones of the tarsus are generally broken by crushing acci- 
dents, such as the fall of heavy weights upon them, by the passage of 
loaded vehicles, etc. 

Pathology. — The astragalus often, indeed generally, escapes without 
injury in those crushing accidents which break many or most of the 
other bones of the foot, and, as we have seen, it is seldom broken 
except when the patient has fallen upon the bottom of his foot ; but 
at the same moment, the foot being turned forcibly out or in, a dislo- 
cation of the tibia takes place, and the fibula is broken. In nine of 
the cases collected by Monahan, one or the other of these forms of 
dislocation had occurred, in eight of which the dislocation was com- 
pound. The direction of the fracture is found to vary greatly ; thus, 
it has been found broken in its length antero-posteriorly, in its breadth 
or transversely, and in one instance it has been divided nearly hori- 
zontally, so as to separate the upper face completely from the lower. 
Sometimes it suffers a species of impaction, the fragments being actu- 
ally driven into each other ; at other times, as in one case related by 
Amesbury, the bone may be split without the occurrence of any dis- 
placement. 

The calcaneum also may be broken in any direction, and it is equally 
with the astragalus liable to impaction, by which its vertical diameter 
is sensibly diminished, while its transverse diameter is increased. If 
the fracture is a consequence of muscular action, the line of fracture is 
always posterior to the astragalus, and in some cases only that portion 
is broken off to which the tendo Achillis has its attachments. It may 
be broken also vertically, directly underneath the astragalus, in which 
case the lateral and interosseous ligaments will prevent anything more 
than a slight displacement of the posterior fragment. When the frac- 
ture takes place posterior to the lateral ligaments, the detached frag- 
ment is liable to be drawn very far from the body of the bone, even to 
the extent of four or five inches, and possibly farther when the leg is 
extended upon the thigh and the foot flexed upon the leg. Constance 
relates a case in which the tuberosity, having been broken off by a direct 
blow, was drawn up five inches. 3 

Fractures of the calcaneum produced by contraction of the sural 

1 South, Notes to Chelius's Surgery, vol. i. p. 639, Amer. ed. 

2 B. Cooper's ed. of Sir Astley, Amer. ed., p. 311. 

8 Constance, Amer. Journ. Med. Sci., vol. v. p. 222, Nov. 1829, from the Midland 
Med. and Surg. Reporter. 



564 FRACTURES OF THE TARSAL BONES. 

muscles are generally simple, but those which result from a crushing 
of the bone are more often compound. The same remark is applicable 
also to the other bones of the tarsus, the fractures of which, being only 
produced by direct blows, are generally complicated with external 
wounds. 

Symptoms. — All fractures of the bones of the tarsus demand especial 
care in their diagnosis, since only a few of the usual signs of fracture 
are in a majority of the cases presented. The explanation of this fact 
will be found in the number, size, and strength of the bones of the 
tarsus, and in their close and firm union by ligaments, by which they 
give to each other a mutual support, so that the fracture of a single 
bone does not necessarily or usually result in displacement or deformity, 
and even crepitus is with difficulty detected ; and when we consider, 
moreover, that the fracture is generally produced by great violence, 
directly applied, in consequence of which the foot in most cases becomes 
rapidly and enormously swollen, we shall understand the true nature of 
the difficulties which are usually presented in the way of an accurate 
diagnosis. 

Of all the usual signs of fracture, crepitus alone is pretty generally 
present, but even this often fails to tell us which bone is broken, and 
still more often does it fail to inform us as to the direction and extent of 
the bony lesions. 

If the whole or a portion of the tuberosity of the calcaneum is sepa- 
rated by the action of the muscles, and the fragment is drawn upwards, 
it may be discovered in its new position, and the heel will be flattened 
or shortened, but no crepitus can be felt unless the fragments are again 
brought in contact. Abel says that in this fracture the foot inclines 
sooner or later to the position of valgus. 1 

Treatment. — Not any of the fractures of the tarsal bones in them- 
selves demand the use of splints, and it is only when complicated Avith 
a dislocation of the ankle and fracture of the fibula that it is proper 
to employ apparatus of this sort ; certainly the exceptions to this rule 
must be very rare ; so that our practice in these cases will be confined 
chiefly to the prevention and reduction of inflammation. This will be 
the sum of the treatment demanded during the first few days after the 
receipt of the injury in probably all cases of simple fracture, and in 
many cases of compound fracture. 

If single bones, or fragments of single bones, are displaced to any 
considerable extent, and there is an external wound communicating 
with the fracture, I have no doubt it would be best in all cases to re- 
move at once by dissection the projecting bone, even although it were 
possible, or perhaps easy, to force it back again to its place, as has been 
done successfully by Ashhurst, of Philadelphia. 2 . The same rule I 
would apply to examples of fracture uncomplicated with any external 
wound, if the fragments were very much displaced, and could not by 

1 Abel, Hosp. Gazette, Nov. 21, 1878, p. 410, from Arcliiv fur Klin. Chir., Band 
xxii. 

2 Ashhurst, Amer. Journ. Med. Sci., April, 1862. 



FRACTURES OF THE TARSAL BONES. 565 

the application of moderate force be replaced, since the bone left to 
project would prevent the patient from ever wearing a boot with com- 
fort, and would entail as much weakness upon the limb as would be 
likely to follow from its complete separation. But such cases as I 
have last supposed are exceedingly rare ; indeed, I have never met with 
a simple fracture of a tarsal bone accompanied by displacement. 

N orris has, however, reported a case of fracture of the astragalus 
accompanied by displacement of about one-half of the bone, but with- 
out any lesion of the soft parts. This was in the person of a man ast. 
30, who was admitted into the Pennsylvania Hospital on the 26th of 
Sept. 1831. "An hour previous to admission, while descending a 
ladder, he slipped and fell in such a manner as to throw the entire 
weight of his body upon the outer part of his left foot. Upon examina- 
tion, the foot was found to be turned inwards and nearly immovable. A 
slight depression existed immediately below the lower end of the tibia, 
and there was a considerable hard and rounded projection on the outer 
part of the foot, a little below and in front of the extremity of the fibula. 
The skin covering this projection was reddened, but not excoriated. 
There was no fracture of either bones of the leg." 

These appearances led Drs. Norris and Barton, under whose care the 
patient was placed, to regard the accident as a simple luxation of the 
astragalus forwards and outwards; and a short time after admission 
efforts were made to reduce it. " This was done, after relaxing in as 
great a degree as possible the muscles of the leg, by fixing the knee, 
and having assistants to keep up extension, by seizing the heel and front 
part of the foot; at the same time the bone being pushed inwards and 
toward the joint by the surgeon. These efforts were continued for a 
considerable time, but had no effect in changing the position of the 
bone. 

" Six hours afterwards Drs. Huston and Harris saw the patient in 
consultation, when efforts were again made at reduction, which not 
proving more effectual than in the first trial, the excision of the bone 
was determined on. 

" The patient being properly placed, an incision was made through 
the integuments, parallel with the course of the tendons, commencing 
a short distance above the projection on the foot, and extending down 
far enough to expose fairly the astragalus and its torn ligaments. The 
bone was then seized with forceps, and easily removed after the division 
of a few ligamentous fibres that continued to connect it to the adjoining 
parts. 

"Very little hemorrhage occurred, two small vessels only requiring 
the ligature. 

" After removal it was discovered that about one-half of the surface 
which plays in the lower end of the tibia had been fractured, and re- 
mained firmly attached to the extremity of that bone, and as it was 
judged that the efforts to remove this would be likely to produce more 
injury to the joint than would arise from allowing it to remain, no 
attempt was made to extract it. 

" The joint being carefully sponged out, the sides of the incision were 
brought accurately together by means of sutures and adhesive straps, 



566 



FRACTURES OF THE TARSAL BONES. 



Fig. 243. 



after which simple dressings and a roller were applied, and the foot, 
restored to its natural situation, placed in a fracture-box." 

Subsequently that portion of the astragalus which was permitted to 
remain, having become carious and loosened, was removed also. 

The case continued to do badly; ail the bones of the tarsus, and even 
the lower ends of the tibia and fibula, becoming eventually carious ; and 
on the 27th of March, 1853, more than a year and a half after the re- 
ceipt of the injury, the leg was amputated; but no healthy action ensued, 
and the patient soon died. 1 

The result of this case can scarcely be regarded as having settled 
anything in reference to the value of the procedure which I have recom- 
mended. For reasons which seemed satisfactory to the surgeons who 
made the operation, only one-half of the broken bone was removed; 
whether the result would have been different if the whole had been at 
once taken away, we cannot now determine. I have related it, however, 

as the only example of a simple fracture 
with displacement which I have been able 
to find upon record; and in this case, 
several surgeons of merited distinction con- 
curred in the opinion that the protruding 
fragment ought to be removed. 

A fracture of the posterior portion of 
the calcaneum, especially when It has been 
produced by muscular action, constitutes 
an exception to fractures of the tarsal 
bones generally, and demands usually that 
apparatus of some kind should be employed 
in its treatment. 

In order to replace the posterior frag- 
ment when displaced, or to maintain it in 
apposition until a bony union is accom- 
plished, it will be necessary to shorten the 
gastrocnemii by flexing the leg upon the 
thigh and extending the foot upon the leg. 
But to retain the limb in this position it 
will be expedient always to employ appa- 
ratus. A very simple contrivance, how- 
ever, will generally answer all the indica- 
tions. A bandage, padded strap, or a 
stuffed collar may be fastened about the 
thigh just above the knee, and made fast 
to the heel of a slipper by a tape (Fig. 243). 
The apparatus is the same which has been recommended for a rupture of 
the tendo Achillis. 

In addition to this, the limb ought to be covered from the foot up- 
wards as far as the knee with a snug roller, underneath which, on each 
side of and above the detached fragment, ought to be placed suitable 
compresses, the object of the roller being to diminish muscular contrac- 




Apparatus for fracture of tuberosity 
of the calcaneum. 



Norris, Amer. Journ. Med. ScL, vol. xx. p. 379. 



FRACTURES OF THE MET AT ARS AL BONES. 567 

tion, and the compresses being intended to retain the detached piece in 
contact with the main body of the bone. Some surgeons have not found 
it necessary to flex the leg upon the thigh ; but they have contented 
themselves with extending the foot upon the leg, and confining it in this 
position by a splint of wood or gutta-percha laid along the front of the 
leg, ankle, and foot. In still other cases, the fragment has shown so 
little disposition to become displaced as to render no precautions of any 
kind necessary, except to impose upon the patient complete quiet, with the 
limb resting upon its outside and flexed, as in Pott's fracture of the fibula. 

As soon as the inflammation has sufficiently subsided, passive motion 
must be given to the ankle, in order to prevent, as far as possible, the 
anchylosis which is an almost constant result of these accidents. Indeed, 
the patient is fortunate who recovers a tolerable use of his foot after the 
lapse of many months ; nor can he be assured that the inflammation will 
leave these bones and their dense fibrous envelopes for a long period, 
and that it may not result in caries of more or less of the tarsal bones, 
demanding finally amputation of the whole foot. 

We have not intended to speak in this place of those severer accidents, 
accompanied with comminution and extensive laceration, which forbid 
the hope of saving the foot, and for which immediate amputation is the 
only proper resource, but which constitute, in fact, the great majority of 
all the fractures of the tarsal bones. 



CHAPTEE XXXY. 

FRACTURES OF THE METATARSAL BONES. 

These bones can scarcely be broken except by direct blows, and the 
great majority of their fractures are the results of severe crushing acci- 
dents, such as render amputation sooner or later necessary. Of those 
which do not demand amputation, by far the largest proportion are com- 
pound fractures ; of which class the following example will serve as an 
illustration: — 

A man in the employ of one of the railroads which connect with this 
city was run over by a loaded car on the 14th of June, 1856, crushing 
his right arm so as to render its immediate amputation necessary. I 
found also a compound comminuted fracture of the fourth metatarsal 
bone of the right foot. Considerable hemorrhage occurred from the 
wound, but this ceased spontaneously. Cool water dressings were dili- 
gently applied, without splints or bandages, and although some inflam- 
mation and suppuration ensued, the parts finally healed over and the 
fragments united, with only a slight backward displacement at the seat 
of fracture. 

When only one bone is broken, the displacement is usually very 
trivial ; but when several are broken, it may be considerable. Mal- 
gaigne relates an example of this latter accident in which, the three 



568 FRACTURES OF THE PHALANGES OF THE TOES. 

middle bones being broken by the wheel of a carriage, and the integu- 
ments being badly torn and bruised, it was found impossible to retain 
the fragments in place. The patient recovered, and was able to place 
the foot well to the ground, but the proximal fragments continued to 
project upwards upon the top of the foot to such a degree as to require 
a special shoe. 

In a majority of cases the direction of the displacement is backwards 
(upwards), especially when the middle metatarsal bones are the sub- 
jects of the fracture. 

I have in my cabinet a second metatarsal bone broken obliquely near 
its middle, with only a very slight displacement of the lower fragment 
backwards ; and also the cast of a bone which has united with an enor- 
mous backward projection. 

In one instance I have seen the metatarsal bone of the little toe cut 
in two with an axe, and the fragments united in about thirty days, but 
with the lower fragments slightly displaced outwards. 

Delamotte relates a case also in which the first four metatarsal bones 
were cut off, and complete union was accomplished on the fortieth day ; 
at the end of two months the patient walked without lameness. 

Treatment. — If the fragments are not displaced, nothing is required 
except that the foot shall be kept at rest, and the inflammation controlled 
by suitable means. 

In case, however, a displacement exists, it ought to be remedied, if 
possible, since, if only very slight, it may become the source of a serious 
annoyance. If the fragments project upwards, they interfere with the 
wearing of a boot, and if they sink toward the sole, the skin beneath is 
liable to remain constantly tender, and the patient may thus be seriously 
maimed for life. 

In case the displacement is not due to the action of the muscles, but 
only to the nature and direction of the force producing the fracture, or 
to entanglement of the broken ends, and it is likely to cause any of the 
inconveniences which I have mentioned if permitted to remain, it will be 
advisable at once to employ considerable force in the way of pressure, or 
to elevate the fragments through an opening previously made upon the 
dorsum of the foot, calling to our aid even the saw or the bone-cutters, 
if necessary. After which the fragments may be retained in place by 
carefully applied pasteboard splints and compresses. 



CHAPTEE XXXVI. 

FRACTURES OF THE PHALANGES OF THE TOES. 

If fractures of the other bones of the feet are generally of such a 
character as to require immediate amputation, these fractures demand 
this extreme resort still more often. Our experience, therefore, in the 
treatment of fractures of the phalanges of the toes is extremely limited. 



GUNSHOT FRACTURES. 569 

Lonsdale observes that it is not uncommon to find great irritation arise 
after fracture of the great toe ; an inflammation extending along the ab- 
sorbents on the inside of the leg to the groin, causing abscesses to form 
in different parts of the limb, and producing sometimes great constitu- 
tional disturbance. An illustrative case has come under my own obser- 
vation at the Buffalo Hospital of the Sisters of Charity. The patient, 
Morgan McMann, get. 18, was admitted Dec. 23, 1853, having several 
days before received an injury upon the great toe which contused the 
flesh severely and broke the first phalanx. He was then suffering from 
severe pain in the foot and leg, and the absorbents were inflamed quite 
to the groin. Poultices being applied to the foot and cool lotions to the 
limb, the inflammation soon subsided, but not until a portion of the toe 
had sloughed away. Eventually also it became necessary to remove 
some portion of the phalanx, which had died ; after which the wounds 
healed kindly. 

When any of the smaller toes are broken, it will be found easier to 
support the fragments by a broad and long splint which shall cover the 
whole sole of the foot and all the toes at the same time, than to attempt 
to apply a splint to the broken toe alone. If, however, we prefer this 
latter mode, a thin piece of gutta percha will be found altogether the most 
convenient material for the purpose. 

If the great toe is broken, its great breadth may prevent any displace- 
ment, and a well-moulded gutta-percha splint will generally secure a per- 
fect and rapid union. 



CHAPTER XXXVII. 

GUNSHOT FRACTURES. 

Gunshot fractures have already been considered, more or less in 
detail, in the several portions of this work, wherever it seemed to be 
necessary to call especial attention to them. This chapter will be de- 
voted, therefore, to a brief resume of my own observations and conclu- 
sions in this department ; to which will be added a few general statistical 
statements, drawn chiefly from the published records of the late war. 

Causes. — Gunshot fractures are caused by a great variety of missiles, 
such as musket and rifle balls, solid shot and shell, grape, canister, 
shrapnel, chain and bar shot, fragments of iron, stone, splinters of wood, 
etc. etc. The only qualities which these missiles possess in common is, 
that they are all projected by the elastic power of gunpowder, and gene- 
rally strike the body with great force ; and that they cause fractures by 
direct violence — seldom if ever by counter-stroke. 

Round, smooth balls frequently impinge upon bones without causing a 
fracture, for the reason that they are easily deflected : and this happens 
especially when they are not moving with great velocity. 

Conical rifle-balls seldom fail to fracture the bones which lie in their 
direct course ; never, perhaps, when, at the moment of contact, the ball 
37 



570 GUNSHOT FRACTURES. 

is moving with its average velocity. The peculiar destructiveness of this 
missile is due to its weight, momentum, and form. 

Canister, grape, shrapnel, solid shot, shells, chain and bar shot, are 
still more destructive ; generally tearing the limbs from the body in such 
a manner as to render readjustment and restoration impossible. 

Pathology. — These fractures may be simple, compound, comminuted, 
or complicated ; and in addition to these common varieties of fractures 
there is occasionally presented an example of simple "perforation," or 
mere penetration of the bone without fissure or other fracture ; and still 
more frequently are seen examples of perforation with fissures. 

Probably ninety-nine per cent, of all gunshot fractures are both com- 
pound and comminuted ; the comminution being, in general, excessive. 

As, in gunshot wounds of the soft parts, it has been generally observed 
that the point of entrance is more round, more smooth, and somewhat 
smaller than the point of exit, and that the tissues are a little depressed 
at the entrance, while they are slightly protruded at the exit; so also in 
gunshot fractures it will often be found that the side of the bone on which 
the ball has entered, or upon which it first impinged, is less comminuted 
than the opposite side ; and, if it is a " perforation," that the opening is 
smaller upon the one side than upon the other ; that the edges are slightly 
depressed upon the one side, and elevated or protruded upon the other ; 
and, finally, that numerous small, as well as some large, fragments of 
bone have been carried into that portion of the track of the wound which 
lies between the bone and the point of exit of the missile. 

"When a ball fractures the shaft of a long bone, although the blow may 
have been received three, four, or even six inches from an articulation, 
the comminution or a single longitudinal fissure may sometimes be found 
extending into the joint. These fissures or splittings of the shaft often 
extend also a long distance up or down, without terminating in the joint. 

Perforations without fissure occur most often in the broad bones of the 
pelvis, in the scapula, or in the spongy extremities of the long bones. In 
the latter, however, it is exceedingly rare to find perforation without fissure. 

Perforations with fissure are pretty common in the head of the humerus 
and in the head of the tibia ; they occur also, but less often, in the lower 
ends of the femur and tibia, in the trochanteric portion of the femur, 
and in the head of the femur. We wish to be understood to say that 
fissures occur less often at the points last mentioned, simply because per- 
forations are there less common. It must be known that if perforations 
do occur at these points, a splitting or fissure communicating with the 
joints is almost inevitable. A misunderstanding here would lead to a 
very fatal error in many cases. 

Prognosis. — In general it may be stated that gunshot fractures of the 
upper extremities do not demand amputation, and that similar injuries in 
the lower extremities do demand amputation. 

This statement is very broad, and cannot be understood except by a 
consideration of these accidents somewhat in detail. Thus : — 

Gunshot fractures of the clavicle, scapula, of the shaft of the humerus, 
of the shafts of the radius and ulna, and of the carpal, metacarpal, and 
phalangeal bones, notwithstanding these bones have suffered extensive 
comminution, do not usually demand amputation ; they will in most cases 



GUNSHOT FRACTURES. 571 

eventually unite, and give to the patients tolerably useful limbs. If, 
however, at the same time that the shaft of the humerus, or of the radius 
and ulna, is thus broken, the large nervous trunks are torn asunder, so 
that the extremity is cold and insensible, the limb cannot probably be 
saved, nor, if it could be, would it be of any value. Destruction of the 
main artery supplying the limb diminishes the chance of its being saved, 
but does not, in the case of the upper extremities, necessarily demand 
amputation. 

Penetration of the shoulder-joint by a musket or rifle ball, producing 
a fracture of the head of the humerus or of the glenoid cavity of the 
scapula, demands amputation when either the axillary artery or axillary 
nerves are injured ; but resection can generally be practised with a rea- 
sonable chance of success when the arteries and nerves are untouched. 
Resection is also made successfully at the shoulder-joint in some cases 
where larger missiles have traversed the joint, such as canister, frag- 
ments of shell, etc. 

Penetration of the elbow-joint by a large shot, or by a Minie rifle- 
ball, the missile fairly entering or traversing the joint, demands amputa- 
tion when the main arterial and nervous supplies are cut off, and resection, 
generally, when both remain uninjured. Resection may be attempted at 
the elbow-joint, also, in some cases where, the nervous supply remaining 
good, only one of the principal arterial trunks is cut off. 

Frequently a ball strikes the outer or inner condyle of the humerus, 
making but a small opening into the joint, and producing only slight 
comminution, and in such cases we often save the limb with more or less 
anchylosis, and without resection. 

The remarks which we have made in reference to gunshot fractures of 
the elbow-joint apply, almost without qualification, to the same accidents 
at the wrist-joint. 

For gunshot wounds with fracture of the carpal, metacarpal, and pha- 
langeal bones we seldom practise either resection or amputation, unless 
the soft parts are almost completely torn away. 

The prognosis which, as we have now seen, is so favorable in the upper 
extremities, will be found very different in the lower extremities ; indeed, 
it is almost reversed. Thus: — 

Gunshot fractures of the shaft of the thigh, of the shafts of the tibia 
and fibula, and of the tarsal bones, generally demand amputation ; or, 
to be more precise, gunshot fractures of the head and neck of the femur 
almost always terminate fatally under amputation or excision, and equally 
under treatment as fractures, that is, where an attempt is made to save 
the limb without interference with the knife. The same accidents in the 
upper third of the shaft of the femur are generally fatal ; but if the 
main artery and the principal nerves are uninjured, the life is, in general, 
less hazarded by an attempt to save the limb than by amputation. In 
the middle third, under the same circumstances, the chances may be con- 
sidered equal, as between amputation and the attempt to save the limb 
by apparatus ; in the lower third the chances are in favor of amputation. 

The above statements in relation to fractures of the femur are based 
mainly upon my own experience, and have been carefully considered. 

I have seen no resections of the knee-joint, and but few of the shaft 



572 GUNSHOT FRACTURES. 

of the femur, after gunshot fractures, which have not terminated fatally; 
and I am convinced that they should never be attempted in fractures of 
the thigh, unless it be that case which presents so little hope in any di- 
rection, viz., gunshot fracture of the head or neck of the femur. 

Gunshot fractures of the shafts of both tibia and fibula demand ampu- 
tation where the comminution is extensive, or the pulsation of the poste- 
rior tibial artery is lost, or the foot is cold and insensible. We do not 
mean to say that some limbs thus situated have not been saved, but only 
that the attempt to save such limbs greatly endangers the life of the 
patient, while amputation at or below the knee is relatively safe. 

Amputation is the only safe expedient in deep penetrating wounds of 
the tarsal bones produced by missiles of the size of musket-balls or larger. 
The only exceptions, which can safely be made, are in cases where balls 
have opened partially and superficially these articulations. 

Resections at the ankle-joint are much more hazardous than amputa- 
tions, and scarcely to be preferred, in army practice, to attempts to save 
the foot without surgical interference. 

Treatment. — While considering the prognosis in these accidents, I have 
necessarily spoken of the treatment in certain cases ; especially with a 
view to the propriety of amputation or resection. It remains only to 
speak briefly of the treatment of those cases in which we may attempt 
to save the limb without resection, properly so called ; for we must not 
forget that pretty often we find it necessary to remove small, loose frag- 
ments of bone by the finger, or by the aid of the knife, or to resect sharp 
points with the saw or the bone-cutters, when we do not practise " resec- 
tion," in the sense in which this term is usually employed by surgical 
writers. 

I shall take the liberty, in this connection, of reproducing what I have 
written elsewhere in relation to gunshot fractures, since it comprises 
nearly all that seems necessary to be added upon this subject. 1 

" If an attempt is made to save a limb badly lacerated and broken, 
certain conditions in the treatment are necessary to success. 

"All projecting pieces of bone which cannot be easily replaced and are 
not firmly attached to the soft parts, must be at once cut or sawn away. 

"All foreign substances, such as fragments of balls or other missiles, 
pieces of cloth, wadding, dirt, etc., must be removed. 

" Any portions of integument, fascia, or muscles, which are entangled 
in the wound, and prevent a thorough exploration, or may obstruct the 
free escape of blood or of matter, must be freely divided. 

" Counter- openings must be made at once, or at an early period after 
the formation of matter, to insure its easy escape (and in certain cases 
a drainage tube must be carried through both wounds). 

" The limb must be placed in an easy position, and not confined by 
tight bandages or forcibly extended by apparatus. 

" The inflammation must be controlled by constitutional and local 
means, and especially by the use of water lotions whenever their em- 
ployment is practicable." 

If joints are implicated seriously, and an attempt is still made to save 

1 Treatise on Military Surgery, by Frank Hastings Hamilton. 1 vol., 8vo. Pub- 
lished by Bailliere Brothers. New York, 1861; also enlarged ed. of same work in 1865. 



GUNSHOT FRACTURES. 



573 



the limb, the joint surfaces must be laid freely open, so as to prevent all 
possibility of the confinement of blood, serum, or pus ; and the joint 
must be placed perfectly at rest, without adhesive strips, bandages, or 
any apparatus which shall compress the limb or embarrass its circulation. 



Fig. 244. 









W 



Jl 



Author's movable canvas. 



I do not know that it is necessary to speak more particularly of the 
treatment of gunshot fractures, unless it be to say that I still give the 
preference, in fractures of the femur, to the straight position. In most 
cases I have preferred my own apparatus, already described when speak- 
ing of fractures of the thigh in general, with moderate extension; and 
by moderate extension is to be understood such as may be effected with 
from five to ten pounds. 

Fig. 245. 




Movable canvas, -with extension, on "horses." 



A movable canvas, such as is shown in the accompanying wood-cuts with 
a hole in the centre, and reinforced by an additional piece of canvas 
where the weight of the hips rests, will enable the surgeon to move his 
patient and clean the bed when necessary. The standard which supports 
the pulley can be received in a slot in the frame. 



574 



GUNSHOT FRACTURES. 



An apparatus similar to this was used, during our late war, in the 
Lincoln General Hospital at Washington. 

I have also used, with the movable canvas, and upon an ordinary bed, 
Hodgen's apparatus, or " cradle," as he terms it, and have found it ex- 
ceedingly useful, and much preferable to any form of double-inclined 
plane, whether suspended or not. The cradle is simply a skeleton-box, 
of the length of the thigh and leg, made of light strips of wood. Across 
the two upper bars are laid, transversely, cloth bands, upon which the 
limb is laid at full length, 1 

Fig. 246. 




Fig. 247. 




Hodgen's apparatus for gunshot fractures of the thigh. 

Of gunshot fractures of the femur many hundreds, probably many 
thousands, during and since the close of our civil war, have come under 
my observation ; but of these, only 92 have been made the subject of 
especial record. Of this number, 75 were fractures of the shaft of the 
femur ; 9 being fractures of the upper third ; 36 of the middle third ; and 
30 of the lower third. Nearly all of these fractures were caused by the 
conical rifle-ball. They were treated in various Federal and Confederate 
hospitals by a great variety of methods, and under a variety of circum- 
stances, which latter were sometimes favorable and sometimes unfavor- 
able. The results may, therefore, be regarded as furnishing a fair basis 
for conclusions as to what may reasonably be expected in army surgery, 
or during the progress of a great war. I have a strong conviction, how- 
ever, that if in an equal number of cases the straight position, with 
moderate extension, were to be employed, and the circumstances were as 
favorable as are usually found in civil hospitals, the results would be 
considerably better than are here shown. Indeed, my own recorded 
cases show, in a marked degree, the advantages of the straight position, 
with slight extension, over the double-inclined planes. In a number of 



1 Hodgen, Treatise on Military Surg., by the author, p. 408. 



GUNSHOT FRACTURES. 575 

these cases, while the limb was flexed, the shortening and bending were 
excessive, and the substitution of Buck's apparatus, Hodgen's, or my 
own, has made at once a great improvement in both regards, besides 
contributing manifestly to the comfort of the patients. 

The average shortening, in those fractures of the shaft of the femur 
which were measured by myself after union was effected, was, in the 
upper third, two inches and one-eighth ; in the middle third, two inches 
and one-quarter ; and in the lower third, a little more than one inch and 
a half. In the upper third three were shortened two inches or more ; 
the greatest shortening being three inches and one-quarter. In the 
middle third, twenty were shortened two inches or more, six three inches 
or more, two four and a half, and one five inches. In the lower third, 
two were shortened two inches or more ; the greatest shortening being 
two inches and three-quarters. 

In a large proportion of the cases the thigh was bent at the point of 
fracture, the bend being in most cases outwards, or to the fibular side of 
the limb. Where N. R. Smith's suspension apparatus was used, the 
bend was usually backwards, while in most of the cases treated in the 
straight position, with moderate extension, the limb was nearly or quite 
straight. 

It is somewhat remarkable that in this table of ninety-two cases there 
are only three examples of union delayed beyond four months, and one 
of these patients was evidently about to die. In a pretty large propor- 
tion of cases the union was not delayed much beyond the usual period of 
union for a simple fracture, although the limb might be much shortened 
and crooked, and still discharging pus, with fragments of bone occasion- 
ally. 

Among the cases which have come under my especial notice are a few 
of peculiar interest, and which deserve to be particularly mentioned. 

Limb Lengthened. — Melchior Brietel, private 12th N. Y. Volunteers, 
was wounded in June, 1862, at the battle of White Oak Swamp, Va., 
by the fragment of a shell, which struck the left leg three inches above 
the condyles. He was taken to Richmond as a prisoner, and about a 
month later he was exchanged and sent within our lines. January 1, 
1864, I found him in the United States General Hospital at Newark, 
under the charge of Surgeon Taylor. The wound was still discharging 
matter occasionally, and several fragments of bone had been removed. 
Splints were not applied until after his exchange. No extension was 
ever employed. At the end of four months he began to walk about 
with crutches. 

On measuring I found this limb lengthened half an inch, and this 
measurement was confirmed by Surgeon Taylor and others. There was 
no anchylosis at the knee-joint. 

It is doubtful whether, in this case, the shaft was broken across en- 
tirely ; if it was, probably no displacement ever occurred. The most 
reasonable supposition is that the fragment of shell entered the bone, 
and that it was in the bone at the time of my last examination, and that, 
in consequence of its presence, the bony structure had become hyper- 
tonic, and had undergone hypertrophy in the direction of the axis of the 
limb. 



576 GUNSHOT FRACTURES. 

Perforating and Penetrating Wounds of the Femur. — James S. 
Mussey, of 16th N. Y. Volunteers, was wounded at Gaines's Mill, June 
27, 1862, probably by a round ball. The ball entered the right nates 
from behind, passing entirely through the right trochanter ; a finger 
could be thrust through the round, smooth hole in the bone. When I 
saw him, three months after the accident, at Baltimore, under the care 
of Surgeon Hasson, the wound was still discharging pus, but in no other 
way was the injury causing either local or general disturbance. 

At the same time, also, my attention was called to the case of Henry 
Voger, 20th Mass. Volunteers, who was wounded, June 30, 1862, at 
the battle of White Oak Swamp, Va. A ball had entered the lower 
end of the femur, near the joint, in front, but did not pass through, 
and had not, up to this time, been found. Three months had passed 
since the injury was received, and the wound was now entirely closed, 
the knee-joint being anchylosed ; but in other respects the condition of 
the limb was almost normal. At no time was there much inflammation 
of the soft parts in the neighborhood of the injured structures. 

Sergeant Lewis Monell, of the 119th N. Y. Volunteers, was wounded 
July 1, 1863, by a ball, which entered on the outside of the left thigh, 
within one inch of the lower end of the femur, passing forwards, and 
emerging in front above the patella. Four months after the accident I 
found him at the Fifty-first Street United States General Hospital, New 
York City. Several fragments of bone had escaped ; the limb was bent 
to an acute angle, and pus was still discharging from the wound. There 
was no effusion into the joint, and his ultimate recovery seemed to be 
assured. 

H. 0. C. was a private in the French army in the Crimea, when he 
was wounded in his left leg by a ball which passed through the bone 
from before backwards just above the patella. Synovia with pus dis- 
charged for several months, and three small fragments of bone escaped. 
In seven months the wound became permanently closed. When I exam- 
ined the limb in 1861 the joint was a little deformed, and slightly anchy- 
losed, but in other respects sound. 

These examples of recovery after gunshot injuries of the femur in the 
vicinity of the knee-joint must be understood to constitute rare excep- 
tions to the rule. In most cases such perforations have been accom- 
panied with longitudinal fissures involving the joint, as is illustrated in 
Fig. 1 of this volume ; and attempts to save the limbs have resulted in 
the loss of the lives of the sufferers. 

Fracture from Duelling Pistol ; Recovery without Lameness. — In 
the somewhat famous duel fought between J. C. Breckenridge and 
Frank Leavenworth, on Navy Island, June 7, 1855, with duelling 
pistols, at ten paces, Breckenridge was shot in the calf of the leg, and 
Leavenworth through both thighs. After Leavenworth fell he was 
carried in a small boat to a point known as Fort Schlosser on the 
American side of the Niagara River, and placed in a wooden cabin, the 
only tenement in the place. I was at once summoned, but did not 
reach there until the following day. Drs. Grimes, Church, and Ware 
were already present. We found that the bullet had entered his right 
thigh about eight inches above the knee, and passed through the limb 



GUNSHOT FRACTURES. 577 

in front of the bone. The ball then entered the left thigh a little 
further back and a little lower down, striking the femur and breaking it 
about five or six inches above its lower end. Here the ball was arrested, 
probably being deflected and becoming lodged in the flesh, and it was 
never found ; nor did it ever afterwards cause any trouble. 

I visited Leavenworth, in consultation with Drs. Ware and Church, 
once or twice each week until his recovery was complete. During the 
first few days no apparatus was applied, but the broken limb was sup- 
ported by junks, and both limbs were kept cool and moist with evapo- 
rating lotions. On the eighth day a long side-splint was applied 
(Boyer's), with a perineal band for counter-extension, and a screw for 
extension. The amount of extension was varied from day to day, but 
it was never more than could be comfortably borne. Still later short 
side or coaptation splints w^ere applied. At the end of eight weeks the 
long splint or extending apparatus was removed, and a few days after 
the coaptation splints. Eleven weeks after the accident he was on 
crutches. The femur was then found shortened half an inch, and per- 
fectly straight. 

Mr. Leavenworth survived this injury many years, and, although he 
led a very active life, he never suffered any inconvenience from the 
wounds in either limb, and his gait was perfect. 

It is probable that in this case there was no comminution of the bone ; 
and I think the same thing has happened under my observation several 
times, where the femur has been broken by a round ball, or by a conical 
ball whose force was nearly expended. A conical ball at short range, 
when it strikes the shaft of the femur fairly, can never fail to cause 
extensive comminution. 

Missiles remaining in the Bone. — Lieutenant Champlain (subsequently 
Commodore) was wounded by a bullet, in 1813, during a sortie from 
Fort Erie, on the Niagara frontier. The ball entered about the middle 
of his thigh and buried itself in the bone. Subsequently Dr. William 
Gibson, of Philadelphia, and, still later, Dr. Nathan Smith, of New 
Haven, attempted the removal of the ball, but without success. 

During all of his long and active life his limb continued to give him 
serious trouble at intervals, and I was several times called to open ab- 
scesses which had suddenly formed, but I was never able to find the 
ball. The limb was firm, somewhat shortened, and strongly rotated 
outwards at the point of fracture. 

Lieutenant Charles Pay son, aid-de-camp to General Devins, was 
wounded by the fragment of a shell while leading a charge upon a 
portion of the enemy's lines at the battle of Cold Harbor, Va., June 
1, 1861. 

The missile entered about the middle of the left thigh, breaking and 
comminuting the bone. Surgeon Rice, of the 25th Mass. Volunteers, 
removed on the same day one fragment of bone about two inches in 
length by half an inch in breadth, but the piece of shell could not be 
found. On the third day he was taken to Chesapeake Hospital, near 
Fortress Monroe. Subsequently the surgeon in charge removed with a 
saw portions of both fragments. 

October 24th, nearly five months after the receipt of the injury, I 



578 GUNSHOT FRACTURES. 

was summoned to the hospital to see Lieutenant Payson in consulta- 
tion. I found the limb suspended in Smith's anterior splint, the two 
separated ends of the broken femur pointing backwards at an angle of 
45°, and nearly projecting from the wound. This is the position which 
I have seen the fragments take in very many, probably in a majority, 
of the gunshot fractures of the shaft of the femur treated by this ap- 
paratus ; and which vicious position the surgeon had in vain sought to 
prevent in the case of Lieutenant Payson. 

Having removed three or four detached fragments of dead bone, we 
laid the limb in a straight position upon a Hodgen's splint or cradle, 
while permanent extension was made with a weight and pulley secured 
to the leg by adhesive strips. The amount of extension employed was 
eight pounds. The fragments were now in line, and the patient declared 
that he was much more comfortable. 

March 31, 1865, five months after this change in the mode of dressing 
had been adopted, he was brought to New York greatly improved in 
health, the bone firmly united, with a slight outward bend at the seat of 
fracture, and shortened six and a half inches, and with almost complete 
anchylosis of the knee-joint. 

From this time Lieutenant Payson remained constantly under my 
charge for two or three years, when at length the wound became per- 
manently closed, and his health was completely re-established. In the 
meanwhile, however, after his return to New York, the original wound 
discharged more or less constantly, and occasionally abscesses of con- 
siderable size were formed which had to be opened. On the 8th of No- 
vember, 1865, seventeen months after the wound was received, it was 
my good fortune to detect the position of the fragment of shell which 
had caused all this trouble. I had searched for it many times before, 
but on this occasion a Nelaton's probe disclosed an iron-rust mark by 
which I was guided to its bed in the centre of the bone, and from which 
it was at once removed. 

As supplementary to this chapter, it seems proper to add a brief resume 
of the statistics of the late civil war, drawn from the reports of the Sur- 
geon-General, made in 1865 and in 1867. 1 

Of 4167 gunshot wounds of the face, 1579 were accompanied with 
fractures of the facial bones. Of these latter, 107 died, and 891 re- 
covered. The remainder are undetermined. Secondary hemorrhage 
is said to have been the most frequent cause of death. 

Of 187 examples of gunshot injuries of the spine (not including those 
in which the chest or abdomen was penetrated), 180 died. Six of those 
reported as having recovered were examples of fracture of the transverse 
or spinous processes. The seventh is that of a soldier wounded at Chick- 
amauga, September 20, 1863, by a musket-ball, which fractured the spi- 
nous process of the fourth lumbar vertebra, and penetrated the vertebral 
canal. The ball and fragments of bone were extracted, and one year 
after he was reported as " likely to recover." 

Of 359 gunshot wounds of the pelvis (not including those in which the 
abdominal cavity was penetrated), 77 died, and 97 recovered. In the 

1 Circular No. 6 Surgeon-General's Office; also Circular No. 7. 



GUNSHOT FRACTURES. 579 

remainder the result is not ascertained. In 256 cases the ilium alone 
was injured ; in 19, the ischium alone ; in 12, the pubes ; in 32, the 
sacrum ; and in 40 cases the lesions extended to two or more portions of 
the innominata. Pyaemia was a frequent cause of death. 

Of 1689 gunshot fractures of the humerus, 436 died, and 1253 recov- 
ered. Nine hundred and ninety-six of these 1689 cases were treated 
by amputation or resection, with a mortality of 21 per cent. In 693 
cases the conservative treatment was adopted, with a mortality of 30 
per cent. 

Of 68 cases in which attempts were made to save the limb after gun- 
shot injury of the hip-joint, without resection, all died. (I have seen 
two cases of successful treatment of these accidents by the conservative 
plan, and others have been reported.) 

Fifty-three amputations at the hip-joint, made by surgeons in the Fed- 
eral and Confederate armies, including also reamputations, gave seven 
successful results. The fate of two is uncertain. 

Sixty-three excisions at the same joint, made by Federal and Confed- 
erate surgeons, furnished five successful cases. 

Three hundred and thirty cases of gunshot fracture of the upper third 
of the femur, in which neither amputation nor resection was practised, 
gave a mortality of 71.81. Thirty-two cases in which amputation was 
made gave a mortality of 75 per cent. Twenty-two in which resection 
was made, gave a mortality of 81.18. (We have rejected three cases 
given in the report as cured. Two of these were resections of the head, 
and one was merely a " rounding off of sharp edges.") 

Tw T o hundred and thirty-two cases of gunshot fractures of the middle 
third, treated without amputation or resection, gave a mortality of 55.46. 
Ninety -three treated by amputation gave a mortality of 54.83. Fifteen 
treated by resection gave a mortality of 86.66. 

One hundred and seventy-three gunshot fractures of the lower third, 
treated without amputation or resection, gave a mortality of 57.79. Two 
hundred and forty-three amputated — mortality 46.09. Two resected — 
both died. 

Of 308 gunshot wounds of the knee-joint, with or without fracture, 
treated without amputation or resection, 258 died — -mortality 83.76. Of 
the 50 which recovered there were, however, only six or eight in which 
the testimony is unequivocal that the joint was opened. Of 452 ampu- 
tated, 331 died— mortality 73.23. Of 10 resected, 9 died— mortality 
90 per cent. 

Of 696 gunshot fractures of the leg, 169, or 24 per cent., were fatal. 

No analyses have been made of fractures of the smaller bones. 

It is much to be regretted that in these comparative analyses of the 
treatment of gunshot fractures, except in the case of the hip-joint, by 
the three methods, it is not stated whether the amputations or resections 
were primary or secondary. In all secondary amputations and resec- 
tions, which for aught that appears, may have constituted a majority of 
the whole number, the conservative treatment had been tried and had 
failed, and the deaths which followed ought in justice to be charged to 
conservatism, and not to the operation. As the reports now stand, they 



580 



GUNSHOT FRACTURES. 



are of little or of no importance in determining the relative value of con- 
servative and operative treatment. 

From the reports of the Confederate army, as published in the Con- 
federate States Medical Journal, we learn that of 221 cases of gunshot 
fractures of the thigh, treated without amputation or resection, 105 died 
and 116 recovered. The shortest period of recovery was 41 days ; the 
longest, 255 days ; the average, 104 days. The shortest period of fatal 



Fig. 248. 



Fig. 249. 






Gunshot fracture of thigh. Side view. 
(Author's collection.) 



Same. Front view. 



termination was one day ; the longest, 185 days ; average, 52 days. 
Greatest shortening, five inches ; least, half an inch ; average, one inch 
and nine-tenths. 1 

Of 50T amputations for gunshot fractures of the thigh, 250 recovered. 2 



1 Richmond Med. Journ., Feb. 1866, from Confederate States Med. Journ. 

2 Ibid., January, 1866, p. 52. 



PART II. 



DISLOCATIONS 



DISLOCATIONS 



CHAPTEE I. 

GENERAL CONSIDERATIONS. 

§ 1. General Division and Nomenclature. 

A dislocation is the displacement of one bone from another at its 
place of natural articulation. 

Dislocations may be divided into accidental or traumatic, spontaneous 
or pathologic, and congenital. 

Our remarks upon the etiology, pathology, symptomatology, prognosis, 
and treatment of these injuries must be considered as applicable only to 
accidental or traumatic dislocations, unless the fact is in any case other- 
wise stated. 

Accidental dislocations are those in which the bones have suffered dis- 
placement in consequence of the application of a sudden force ; and sur- 
geons have divided these accidents into Complete and Partial, Simple, 
Compound and Complicated, Recent and Ancient, Primitive and Con- 
secutive. 

A complete dislocation is one in which no portions of the articular 
surfaces remain in contact. 

A partial dislocation is one in which the articular surfaces are not 
completely removed from each other. 

A simple dislocation is that form of the accident in which the bone has 
only slid from its articulation, and is accompanied with the least or only 
an average amount of injury to the soft parts or to the bones adjacent 
to the joint. 

A compound dislocation implies that the articulating surface of the 
bone has been thrust through the flesh and skin ; or that in some other 
way a wound has been made which communicates with the joint. 

Complicated dislocation is a term employed by some writers to desig- 
nate a condition wholly differing from a compound dislocation, or, in some 
cases, a condition of extra complication. Thus, a simple dislocation may 
be complicated with a fracture, or with the laceration of an important 
bloodvessel, etc. ; and a compound dislocation maybe complicated in the 
same way, and with the addition, perhaps, of extensive laceration and 
destruction of integument, muscles, nerves, etc. 

A recent luxation has taken place within a period of a few days, or, 
at most, of a few weeks ; and an ancient luxation has existed during a 



584 GENERAL CONSIDERATIONS. 

longer period. The exact point of time at which a dislocation shall be 
called recent or ancient is not fully determined by surgeons, and the 
application of these terms is therefore always somewhat arbitrary. 

A primitive luxation is a luxation in which the bone remains nearly or 
precisely in the position into which it was at first thrown ; while a sec- 
ondary or consecutive luxation is one in which the bone has subsequently, 
in consequence of the action of the muscles, or from unsuccessful efforts 
at reduction, or from some other cause, changed its position sufficiently 
to entitle the accident to a new designation. Thus a primitive disloca- 
tion upon the ischiatic notch may become a secondary dislocation upon 
the dorsum ilii, or the reverse. 

§ 2. General Predisposing Causes. 

Age. — According to Malgaigne, whose conclusions are based upon an 
analysis of six hundred and forty-three cases, dislocations are very rare 
in infancy, only one having occurred under five years ; but the frequency 
increases gradually up to the fifteenth year, from this period more rapidly 
up to the sixty-fifth year, and from this time onward again dislocations 
become more rare. He has mentioned none after the ninetieth year ; 
and the period of greatest frequency is between the thirtieth and sixty- 
fifth year. To this middle period belong four hundred and seven of the 
whole number. 

The inference from this analysis may be thus briefly stated : age, as a 
predisposing cause, is most active in middle life, less active in advanced 
life, and least active of all in early life. 

It is proper, however, to observe that while such statistics may be re- 
lied upon as indicating the relative frequency of these accidents at dif- 
ferent periods of life, they cannot be regarded as determining absolutely 
the value of age alone as a predispoing cause, since the direct or exciting 
causes may be more active at one period than another, and in some 
measure these latter causes may be, and doubtless are, responsible for 
such results. 

Constitution and Condition of the Muscles and Ligaments. — It may 
be stated as a general fact that persons of feeble constitutions, and whose 
muscular systems are much weakened, suffer dislocation from slighter 
causes than those who are in health, and whose muscular systems are 
firm and vigorous ; and that a relaxation of the ligaments which sur- 
round a joint, however this may have been occasioned, predisposes to 
dislocation. Thus, a paralyzed and atrophied limb is predisposed to 
luxation ; a joint in which the capsule has become stretched by effusions, 
or by violent extension, or weakened by laceration from a previous dis- 
location, or by ulceration, or if in any other way the articulation is de- 
prived of these natural protections, we need scarcely say, it is thereby 
rendered more liable to luxation. 

Ball-and-socket joints, other things being equal, are more liable to 
displacement than ginglymoid ; but then much more depends upon the 
relative exposure of the joint than upon its anatomical structure, so that 
the elbow is much more frequently dislocated than the hip ; the shoulder- 
joint, however, being, from its position and extent of motion, peculiarly 



GENERAL SYMPTOMS. 585 

exposed, and being also a ball-and-socket joint, is, of all others, most 
liable to dislocation. 

§ 3. Direct or Exciting- Causes, 

These may be classed under two general heads, namely, external vio- 
lence and muscular action. 

External violence operates either directly or indirectly. When a 
person falls upon the knee and dislocates the head of the femur, the 
force is said to have acted indirectly, and this is by far the most frequent 
mode of dislocation ; but when the blow is received upon the upper end 
of the humerus, and its head is sent into the axilla, it is said to have 
been dislocated by direct violence. 

Muscular action produces a dislocation slowly, as in some cases of 
chronic rheumatism, and then it is called a spontaneous or pathologic 
dislocation : or suddenly, as in the violent spasmodic contractions which 
accompany convulsions : or sometimes by the mere voluntary effort of 
the muscles ; and both of these latter are true accidental luxations. 

It is very probable that external force can seldom be regarded as the 
sole cause of a dislocation, but that, in a large majority of cases, muscu- 
lar action consenting with the shock, performs an important rule in the 
history of the accident. The limb, being driven obliquely across its 
socket by the external violence, is seized by the stretched and excited 
muscles with such vigor as to contribute not a little to the unfortunate 
result. Thus it will be found that the same force which is adequate to 
the production of a dislocation in the living and healthy subject is wholly 
insufficient to accomplish the same in the dead ; and a man who is fully 
intoxicated seldom suffers a dislocation. 

§ 4. General Symptoms. 

As fractures are characterized by preternatural mobility and crepitus, 
to which may be generally added the circumstance that when reduced 
the fragments will not remain in place without external support ; so, on 
the other hand, dislocations are characterized by preternatural rigidity. 
an absence of crepitus, and by the fact that when reduced the bone does 
not generally require support to maintain it in position. 

These three are the usual, and they may be termed the common, signs 
of distinction between fractures and dislocations, but no one of them can 
be alone depended upon as positively diagnostic. Generally, when a 
bone has been dislocated, we shall find the limb in a certain position, 
which is uniform for all dislocations of the same character, and almost 
immovably fixed ; but when the ligaments and muscles about the joint 
have been extensively torn, or the whole body is still suffering under the 
shock, or in any other circumstances where the power of the muscles is 
weakened, this rigidity may give place to extreme mobility. 

True crepitus does not exist without fracture, but is not always present 

in fractures, and there is often a sensation produced in the rubbing and 

chafing of dislocated bones which very much resembles certain kinds of 

crepitus, and by the inexperienced has been often mistaken for it. I 

38 



586 GENERAL CONSIDERATIONS. 

allude to the subdued rasping sound or sensation which is found gene- 
rally on the second or third day, and sometimes earlier, and which is the 
result of fibrinous effusions, or, perhaps, in some instances, of the mere 
rubbing of firmly compressed ligamentous and cartilaginous surfaces 
upon each other. The crepitus of a recent fracture can be scarcely con- 
founded with this obscure sensation, unless it is in some cases of incom- 
plete fracture, or of a fracture situated remote from the surface, as in 
the case of the hip ; but a fracture which is a few days old, whose sur- 
face has become softened by inflammation and more or less covered with 
lymph, when the rigidity is great may sometimes deceive the most ex- 
perienced surgeon, so exactly will it be found to imitate the sensations 
produced by the chafing of an inflamed joint, or of closely approximated 
fibrous surfaces. 

I have said that a true crepitus does not exist without a fracture ; but 
then a very minute fracture, such as the detachment of a scale of bone 
by the tearing away of a tendon or of a ligament, may produce crepitus ; 
or even the separation of a piece of cartilage may sufficiently expose the 
bone to determine the presence of this phenomenon. These are, how- 
ever, no longer examples of simple dislocation. 

Nor are the two inverse propositions, in relation to the retention of 
the bones in place, invariable in their application. A broken bone, well 
reduced, does not always manifest a tendency to displacement ; nor does 
a dislocated limb, when restored to its socket, in all cases maintain its 
position without support. 

The other general signs of dislocation are pain, swelling, and discolor- 
ation. The pain is generally more intense in dislocations than in frac- 
tures, the expanded end of the bone resting often upon one or more 
large nerves, which usually, with the arteries, approach very near the 
joints ; this pressure being also greatly increased by the extreme tension 
of the muscles. Not unfrequently numbness and temporary paralysis of 
the whole limb are the consequences. In other cases the pain is due 
solely to the pressure upon the muscles or to the tension of the muscles, 
or, perhaps, to the tension of the untorn ligaments and capsule. 

Generally the limb is shortened, but in a few cases it is found slightly 
lengthened, while the natural axis of the bone with its socket is always 
changed. If examined early, and before the supervention of swelling, 
the joint end of the displaced bone may be felt in its unnatural position, 
and a corresponding depression may be discovered in the situation of the 
articulation, especially if the bones are superficial. 

§ 5. Pathology. 

The dissection of recent dislocations produced by external violence, 
shows the capsular ligaments more or less torn, and also a rupture of 
some of the lateral and other short ligaments, with a complete rupture in 
most cases of some of the tendons which immediately surround the joint, 
or of those which are attached to the capsule : the muscles, nerves, arte- 
ries, etc., through which the bone in its passage has passed, or upon 
which it is found resting, being also contused, stretched, or torn asunder. 

This description, however, does not apply to dislocations produced by 



PATHOLOGY. 587 

muscular action alone, in a majority of which cases the capsule is only 
stretched, and not torn, and no lesions of other structures are necessarily 
present. 

If the dislocation remains unreduced, the margins of the old socket, in 
the cases of enarthrodial articulations, become gradually depressed, while 
the concavity of the socket is filling in with a fibrous or bony tissue, 
until at length the whole of this portion of the joint apparatus is nearly 
or entirely obliterated. This process is generally very slow, and may 
not be consummated until after the lapse of many years. 

At the same time, but with much greater rapidity, the head of the bone 
in its new position, and the soft or hard parts upon which it rests, are 
undergoing certain changes to adapt them to their new relations, and cal- 
culated in some measure to restore the limb to its normal functions. If 
the head of the bone rests upon muscle, the cellular and fibrous tissues 
which enter into the composition of the muscle become condensed and 
thickened, forming a shallow or elongated cup, whose margins are 
attached to the neck, or shaft of the bone, and whose walls are lubri- 
cated with synovia. If it rests upon bone, by a process of interstitial 
absorption a true socket is formed, sometimes deep and sometimes shal- 
low, whose edges, receiving additional ossific depositions, become lifted 
so as to form a rim. At the same time the head of the bone is under- 
going corresponding changes, to adapt itself to the newly formed socket; 
it is flattened or otherwise changed in form, and in the progress of this 
change its natural secreting and cartilaginous surfaces are gradually 
removed, a porcelaneous deposit taking its place. The same kind of 
hard, polished, ivory-like deposit is found also in those portions of the 
new socket which have been especially exposed to pressure and friction. 
Instead of the eburnation, an imperfect fibro-serous surface or synovial 
capsule may be formed. 

I have in my cabinet an example of ancient luxation of the hip-joint in 
which the head of the femur, having rested upon the dorsum ilii, has 
formed a nearly flat but smooth surface — a kind of elevated plateau ; in 
other cases I have seen the margins of the new socket so elevated as to 
rest against the neck of the femur, and completely lock it in. 

Coincident with these changes, and in consequence partly of the disuse 
of the limb, the muscle, and even the bones sometimes suffer a gradual 
atrophy. In some measure these alterations may be due also to the pres- 
sure of the dislocated bone upon arterial and nervous trunks, by which 
their functions become partially or completely annihilated, and their 
structure even may be wholly obliterated. In consequence also of the 
inflammation which immediately results, we ought not to omit to notice 
that the trunk of a large artery sometimes becomes firmly adherent to 
the capsule or periosteum of a displaced bone, and its reduction is 
attended with imminent danger of laceration and of a fatal hemorrhage. 
Numerous instances of this grave accident, especially in attempts to 
reduce old dislocations of the shoulder-joint, are upon record. 



588 GENERAL CONSIDERATIONS. 

I 6. General Prognosis. 

We shall study the prognosis of these accidents to better advantage 
when we come to speak of the individual bones and their various forms 
of dislocation ; but it is proper to state in this place, generally, that very 
few joints, having been once completely displaced from their sockets by 
external violence, are ever so completely restored as not to leave some 
traces of the accident, for many years, if not for the whole of the subse- 
quent life of the patient, either in the partial limitation of their motions, 
or in the diminished size and power of the muscles of the limbs, or in the 
presence of an occasional arthritic pain : the degree and permanence of 
these sequences depending upon the joint which is the subject of the dis- 
placement, the extent of the original injury, the length of time it has re- 
mained unreduced, the means employed in its reduction, the health and 
condition of the patient, with so many other contingent circumstances as 
to preclude the idea of a complete specification. 

If the bone is not reduced, a permanent maiming is inevitable ; but it 
is surprising how much, time and the intelligent processes of nature can 
eventually accomplish toward a restoration of the natural functions, espe- 
cially when aided by a good constitution and judicious treatment. If the 
symmetry of form and grace of motion are never replaced, the value of 
the limb, for all the practical purposes of life, is not unfrequently com- 
pletely re-established. 

§ 7. General Treatment. 

The first indication of treatment is to reduce the bone. Whatever de- 
lays may be proper or justifiable in certain cases of fracture, such delays 
are never to be argued in cases of dislocation. The sooner the reduction 
is accomplished the better. For this purpose we resort at once to such 
manipulations or mechanical contrivances as the nature of the case de- 
mands ; and if these fail, or if at the first they are deemed insufficient, 
we invoke the aid of constitutional means, or such as are calculated to 
diminish the power and antagonism of the muscles. 

Many dislocations may be reduced promptly by manipulation alone ; 
which mode is always to be preferred when it will prove sufficient, for 
the reasons that it is generally the least painful to the patient, and the 
least apt to inflict additional injury upon the muscles and ligaments. 

A person wholly unacquainted with anatomy or surgery may occasion- 
ally succeed in reducing a dislocated limb ; indeed it frequently happens 
that the patient himself, by mere accident in getting up or in lying down, 
accomplishes the reduction ; and even in a very large majority of cases, 
force and perseverance will finally succeed by whomsoever they may be 
employed ; but the observing student of surgery will soon discover the 
difference between accident and brute force on the one hand, and intelli- 
gent manipulation on the other. The charlatan bone-setter does not 
often allow himself to fail, unless the courage of his patient gives out, or 
he ignorantly supposes the reduction to be effected when it is not ; but 
his success, achieved through great and unnecessary suffering, is often 
obtained, also, at the expense of the limb ; while the surgeon, whose 



GENERAL TREATMENT. 



589 



Fig. 250. 



knowledge of anatomy enables him to understand in what direction the 
muscles are offering resistance, and through what ligaments the head of 
the bone must be guided, lifts the limb gently in his hands, and the bone 
seeks its socket promptly and without disturbance, as if it needed only 
the opportunity that it might demonstrate its willingness to return. 

We must understand not only what muscles and ligaments antagonize 
the reduction, if we would be most successful, but also what muscles, by 
being provoked to contraction, will themselves aid in the reduction. In 
short, to become expert bone-setters in the department of dislocations, 
one must possess a complete knowledge of the physiognomy or the ex- 
ternal aspect of joints, acquired only by repeated and careful examina- 
tions, he must be familiar with the anatomy and functions of the muscles, 
he must understand thoroughly the ligaments, he must have experience, 
tact, and fertility of resource. 

Without these qualifications a man will do better never to undertake 
to treat dislocations, since he is constantly liable to mistake fractures for 
dislocations, and dislocations for fractures ; he will submit a sprained 
wrist to violent extension, under the conviction that the joint is dis- 
placed; he will mistake natural projections for 
deformities, and fail to recognize the real de- 
formity when it actually exists; he will leave 
bones unreduced, fully believing that they are 
reduced ; and he will, all in all, w T ithin a few 
years, accomplish vastly more evil than he can 
ever do good. Let a man practise any other 
branch of surgery if he will, without experi- 
ence or scientific knowledge, but he must not 
attempt to reduce dislocated bones. The most 
learned and the most skilful we shall find fall- 
ing into error, embarrassed by the uncertainty 
of the diagnosis, or successfully resisted by the 
power of the opposing agents ; what then can 
be expected of those who are both ignorant 
and inexperienced, but failures and disasters ? 

As a means of disarming the muscles, or of 
placing them off their guard, we often practise 
successfully the diversion of the mind of the 
patient. At the very moment that the limb is 
moved or extension is made, a question is ad- 
dressed to him, or he may be suddenly sur- 
prised by some unexpected intelligence. 

Extension and counter-extension, made with our own hands or with 
the hands of assistants, constitute the second resort where manipulation 
alone has failed. The surgeon seizing upon the limb firmly with his 
hands, makes the extension, while the assistants make the counter-exten- 
sion; or, instead of grasping the limb directly, the operator may use for 
this purpose circular and longitudinal bandages, or the bandage or hand- 
kerchief tied in the form of the clove-hitch. Extension is thus applied 
in connection with manipulation, aided, perhaps, by direct pressure upon 
the head of the displaced bone. Failing in this, we employ some one 




Clove-hitch. (From Erichsen.) 



590 



GENERAL CONSIDERATION'S 



of the various mechanical contrivances which, while they are capable of 
exerting much more power, possess also the important advantage of ope- 
rating gradually and steadily, by which mode the resistance of the 
muscles is always more speedily and more completely overcome. 

For this purpose surgeons employ generally, in the case of the large 
limbs, the compound pulleys, or the simple rope windlass, which latter 
is thus described by Dr. Gilbert, of Philadelphia : " Place the patient,, 
and adjust the extending and counter-extending bands as for the pulleys ; 

Fig. 251. 





Compound pulleys, and ring to which one end of the pulley-rope is fastened 



then procure an ordinary bed-cord or a wash-line, tie the ends together 
and again double it upon itself, pass it through the extending tapes or 
towels, doubling the whole once more, and fasten the distal end, consist- 
ing of four loops of rope, to a window-sill, door-sill, or staple, so that 
the cords are drawn moderately tight ; finally, pass a stick through the 
centre of the double rope, then by revolving the stick as an axis or 
double lever, the power is produced precisely as it should be in such 
cases, viz., slowly, steadily, and continuously." 

Jarvis's adjuster, although very complex, possesses some advantages 
over the pulleys, which may, perhaps, entitle it to the preference in a 
few cases. 

Among the constitutional means, ether and chloroform occupy the first 
rank; indeed they are, at the present day, almost the only means of this 
class to which surgeons resort, and their value in this point of view can 
scarcely be over-estimated. Only when some unusual circumstance or 
condition of the patient forbade the use of an anaesthetic, would the sur- 
geon return to the ancient practice of bleeding ad deliquium, of pros- 
trating the system with antimony, or to the use of those vastly less 
efficient agents, opium and the warm bath. 



DOUBLE OR BILATERAL DISLOCATION. 591 



CHAPTEE II. 

DISLOCATIONS OF THE LOWEE JAW (TEMPORO-MAXILLARY). 

There are two principal forms of this dislocation, namely, the double 
or bilateral dislocation, and the single or unilateral ; in both of which 
the direction of the displacement is forwards. To these there has been 
added one example of an outward displacement accompanied with a 
fracture. 1 

§ 1. Double or Bilateral Dislocation. 

This form of dislocation of the lower jaw is much the most frequent, 
being met with in about two out of every three cases. It appears also 
to occur oftener in women than in men, and usually between the twentieth 
and thirtieth year of life. In infancy and extreme old age it is exceed- 
ingly rare ; yet Sir Astley Cooper mentions a case in which, " two boys" 
being at play, one had an apple thrust into his mouth, producing a double 
dislocation ; and Nelaton saw the same accident in an old man of seventy- 
two years, who was toothless. 

This comparative immunity in youth and old age has been ascribed to 
certain peculiarities in the form of the jaw at these periods of life. Ne*- 
laton attributes its more frequent occurrence in middle life to the great 
length and strong anterior inclination of the coronoid process. 

In a majority of cases the direct or immediate cause has seemed to 
be muscular action alone. Malgaigne found this cause to prevail in 
twenty-five out of forty cases ; and of the twenty-five cases fifteen were 
occasioned by gaping, five by convulsions, four by vomiting, and one by 
rage. Dr. Physick, of Philadelphia, found both condyles dislocated in 
a woman in consequence of the violent gesticulation of her jaw while 
scolding her husband. But in a more remarkable case still, this surgeon 
found the jaw dislocated after recovery from a profuse salivation, and of 
the cause of which, or the time of its occurrence, the patient, a young 
girl, could give no account. Dr. Physick made several ineffectual at- 
tempts at reduction, and only succeeded at last after he had made her 
completely intoxicated with ardent spirits. 2 

Dr. E. Andrews, of Michigan, found both condyles dislocated by a 
lobelia emetic. The patient had often taken these emetics before, and 
had frequently experienced a sensation " of catching" at the joint, but 
the jaw had always until this time resumed its position spontaneously. 3 

1 Robert, Journal de Chir., 1844. 

2 Physick, Dorsey's Elements of Surgery, vol. i. p. 202. Philadelphia, 1813. 

3 Andrews, Peninsular Journ. Med., vol. iii. p. 101, 1855. 



592 DISLOCATIONS OF THE LOWER JAW. 

Dr. A. H. Steen, of Minnesota, met with a bilateral dislocation caused 
also by vomiting. 1 

Among the causes from outward violence, the introduction of some 
foreign body into the mouth, and the extraction of teeth, occupy the 
most important place. In fifteen cases seven were from the former and 
six from the latter cause. 

My former pupil, Dr. A. W. Gilbert, has related a case which came 
under his own observation, produced by a similar cause. During his 
apprenticeship with Dr. Parsons, a dentist, he was requested to insert a 
set of teeth for a young man residing in Cattaraugus Co., N. Y., and 
while opening his mouth to take an impression of his gums, he dislocated 
" both condyles forwards, under the zygomatic arches ;" but so perfectly 
were the muscles relaxed, that he immediately reduced them, without the 
least difficulty, by placing his. thumbs as far back as possible upon the 
molar teeth, depressing the back part of the jaw, and at the same mo- 
ment elevating the chin. 2 

Prof. James Webster, of Rochester, N. Y., dislocated the jaw of a 
lady while attempting to pry out a root of one of the molars. 

Pathology. — In order that we may better understand the pathology 
of this accident, it will be proper to say a few words in relation to the 
anatomy of the temporo-maxillary articulation and the other parts con- 
cerned in the dislocation now under consideration. 

The articulation is formed by the condyloid process of the inferior 
maxilla and the glenoid fossa of the temporal bone, in front of which 
fossa, and at the root of the zygomatic arch, is a slight elevation, called 
the articular eminence. Between the joint surfaces, both of which are 
covered with cartilage of incrustation, is placed an interarticular carti- 
lage, which divides the joint into two cavities, one corresponding to the 
condyle of the inferior maxilla, and the other to the glenoid fossa, each 
of which is furnished with a distinct synovial membrane. 

Properly there is but one ligament — namely, the external lateral — 
which passes from the outer surface of the articular eminence to the cor- 
responding surface of the neck of the condyle. What is called the in- 
ternal lateral ligament arises from the apex of the spinous process of the 
sphenoid bone, and is inserted into the margin of the dental foramen, and 
has therefore no immediate connection with the articulation, although it 
tends to strengthen the joint. The same is true of the stylo-maxillary 
ligaments. 

The lower jaw is drawn upwards, or closed upon the upper jaw, by the 
action of the temporal, masseter, and internal pterygoid muscles ; it is 
drawn downwards by the action of the digastricus, mylo-hyoideus, and 
genio-hyoglossus muscles ; forwards by a few fibres of the masseter and 
by the external pterygoid muscles ; and laterally by the alternate action 
of the external and internal pterygoid muscles. 

When the mouth is open to its utmost extent, the maxillary condyle 
rises upon the articular eminence until it rests upon its very summit. 
Indeed, it is probable that in most persons it advances rather in front of 

! Steen, Virginia Med. Monthly. June, 1878, p. 220. 

2 Gilbert, Thesis on Dislocation of the Inf. Max. University of Buffalo, 1858. 



DOUBLE OR BILATERAL DISLOCATION 



593 



Fig. 252. 



the centre of the eminence ; so that in order to become actually dislo- 
cated it only needs that the capsule shall be somewhat relaxed, or that 
it shall actually give way in front, when the condyles slide forwards and 
occupy a position directly in front instead of behind this eminence. 

It is easy to comprehend how the combined action of the two external 
pterygoid muscles, with a portion of the fibres of the masseter, may 
alone produce the dislocation when the mouth is wide open, and espe- 
cially when, in consequence of a slight blow upon the chin, the anterior 
portion of the capsule becomes lacerated ; for it must be noticed that 
the ascending ramus, with its prolonged condyloid process, constitutes a 
lever of the first kind, in which the temporal muscle, attached to the 
coronoid process, the masseter, and even the mastoid process, constitute 
the fulcrum, the anterior portion of the capsule, the weight, and the force 
acting against the front of the chin, the power. 

In this position of the condyle, drawn upwards and forwards by the 
action of the pterygoid and temporal muscles, the chin descends toward 
the neck, and the coronoid pro- 
cess rests against the back of the 
superior maxilla, or against the 
malar bone at the point of its 
junction with the upper maxillary. 
The temporal, masseter, and in- 
ternal pterygoid muscles are very 
much upon the stretch, if not more 
or less lacerated. 

Symptoms. — The mouth is 
widely open and the jaw nearly 
immovable. It has been noticed 
generally that, by pressure, the 
chin may be slightly depressed, 
but that, owing probably to the 
pressure of the coronoid process 
against the body of the upper maxilla, or against the malar bone, it is 
generally impossible to elevate the jaw in any degree whatever. 

The jaw is also slightly advanced; a depression, covering a consider- 
able space, exists between the auditory canal and the posterior margin 
of the condyle. A slight fulness is observed in the temporal fossa, and 
also upon the side of the cheek in the region of the masseter muscle. 

Ordinarily the patient suffers considerable pain, but not always, 
from the pressure of the condyles upon the branches of the temporal 
nerves. There is a constant flowing of the saliva from the mouth ; the 
patient is unable to articulate, and even deglutition is performed with 
great difficulty. 

Prognosis. — When the dislocation remains unreduced, the lower jaw 
gradually approximates the upper, and its anterior projection sensibly 
diminishes, the saliva ceases to dribble from the mouth, deglutition and 
speech are restored, mastication is performed with considerable ease, 
and, in short, the patient comes at length to experience no great incon- 
venience from the displacement. 

Robert Smith relates the case of a woman w T hose lower jaw was dis- 




Double dislocation, of the inferior maxilla. 



594 



DISLOCATIONS OF THE LOWER JAW. 



Fig. 253. 



located during an epileptic convulsion. She was at the time in one of 
the metropolitan hospitals, but the accident was not noticed by the 
surgeons, and it remained ever afterwards unreduced. At the end of 
a year she could close the lips perfectly, but was able to open the 
mouth only to a limited extent ; the teeth of the lower jaw remained 
advanced, the involuntary flow of saliva had ceased, and the faculty of 
speech had been regained. 1 In Professor Webster's case, to which I 
have before referred, although the jaw was immediately and easily 
reduced, after the lapse of several years, when I saw the lady, she still 
complained that it hurt her whenever she ate, and that she often felt the 
condyles slip in their sockets. 

Reduction has been accomplished by Physick in the case already 
related after the lapse of several weeks ; Sir Astley Cooper reduced 
a double dislocation after a month and five days, which had been over- 
looked by the surgeon in attendance ; 2 and Donovan succeeded after 
ninety -five days. 3 

Treatment. — Reduction may generally be accomplished with ease in 
cases of recent luxation, in the following manner : The patient being 

seated upon the floor with his head 
between the knees of the operator, a 
couple of pieces of cork, gutta-percha, 
or pine wood are placed as far back 
between the molars as possible, when 
the surgeon seizing upon the chin 
draws it steadily upwards, taking care 
not to draw it forwards at the same 
time, since by this movement he would 
resist the action of the muscles which 
naturally tend to restore it to place 
whenever the condyloid processes are 
lifted sufficiently from the zygomatic 
fossae. Many surgeons prefer to sit 
or stand in front of the patient, and 
depress the condyles by means of the 
thumbs placed inside of the mouth 
and upon the tops of the molars. If 
the thumbs are used in this way, it 
would be well to protect them with a 
piece of leather, or to slip them off 
from the teeth suddenly when the 
condyles are gliding into their places, as the muscles sometimes close 
the mouth with sufficient violence to bruise severely anything which 
might at this moment be interposed between the teeth. 

The method practised by Ravaton, of simply lifting the chin gradu- 
ally and forcibly toward the upper jaw, was essentially the same, but 
far less efficient ; for, although he placed nothing between the molars 




Double dislocation of the inferior maxilla. 



1 Robert Smith, on Fractures and Dislocations. Dublin, 1854, p. 288. 

2 Sir Astley Cooper, on Disloc. and Frac, Auier. ed., p. 316. 

3 Donovan, Amer. Journ. Med. Sci., Oct. 1842, p. 470 ; from Dublin Med. Press, 
May 25, 1842. 



SINGLE OR UNILATERAL DISLOCATIONS. 595 

to serve as a fulcrum, the backmost teeth themselves must in some 
degree perform this service whenever, the lower jaw being dislocated 
and drawn upwards, the chin is forcibly approximated toward the 
upper. 

In other cases it has been found necessary first to disengage the coro- 
noid process, by depressing the chin gently, and then pressing backwards 
in the direction of the articulation ; a method which would certainly de- 
serve a trial in case of the failure of that first described. This was the 
method practised by Hippocrates. 

A more effectual expedient, however, consists in reducing one side at 
a time ; taking good care always that the side first reduced is not relux- 
ated while the attempt is being made to reduce the other, a thing which 
happened in one of the cases treated by Sir Astley Cooper, and has 
happened many times in the practice of other surgeons. 

Finally, if all other expedients fail, we ought not to hesitate to resort 
to anaesthetics, nor indeed could any objection exist to their employment 
at any period of the treatment, were it not that in a large majority of 
cases the reduction is effected so easily and promptly as to render their 
employment wholly unnecessary. 

After the reduction is accomplished, it will be a matter of wise precau- 
tion to sustain the jaw by a double-headed bandage passed under the 
chin, and secured upon the top of the head ; so as to prevent the mouth 
from being accidentally opened too far, especially during sleep, since 
experience has shown that a tendency to a reproduction of the disloca- 
tion remains for some time. It will be prudent to continue these measures 
of protection for at least one week ; after which the danger of anchylosis 
should be borne in mind, and the extent of passive motion should be 
gradually and cautiously increased. In illustration of this tendency to 
reluxation, Malgaigne refers to the case mentioned by Putegnat of a 
woman whose jaw for many years became luxated at least once a month; 
but she was always able to reduce it herself. 

§ 2. Single or Unilateral Dislocations. 

The causes of this accident are in general the same as those which 
produce double dislocations, and it occurs most often in middle life. 
Tartra has seen one exceptional example in a child only fifteen months 
old, and Levison saw a case in an old man who had lost all his teeth. 1 

Symptoms. — The mouth is open, but not so widely as in double dislo- 
cation ; the jaw is nearly immovable ; the teeth are advanced ; the con- 
dyloid process can be felt in front of the articular eminence, leaving a 
depression in its natural situation, and the coronoid process is more promi- 
nent than in the bilateral dislocation. 

It will be remembered that we have already pointed out an important 
diagnostic mark between a fracture of the neck of the condyloid process 
and a dislocation of one condyle. In the latter the chin inclines to the 
opposite side, while in the former it falls toward the side upon which the 

1 Levison, Boston Med. and Surg. Journ., vol. xxxiv., 1846, p. 388, from London 
Lancet. 



596 DISLOCATIONS OF THE LOWER JAW. 

accident has occurred. According to Hey, this lateral deviation of the 
chin is not always present in dislocations ; and Robert Smith mentions 
one case in which the surgeon was misled by this circumstance so far as 
to attempt a reduction upon the left side when the dislocation was upon 
the right. 

Treatment. — The same rules of treatment which we have established 
for dislocations of both condyles will be applicable to the single disloca- 
tions, with only such modifications as will be naturally suggested to the 
surgeon. 

In the case mentioned by Levison, the dislocation was constantly re- 
curring upon the left side ; and it was especially liable to happen w T hen 
just awakening from sleep. "He would then pull his jaw, press it back- 
wards, when, after about half an hour's work, bang it seemed to go, and 
all was right again." This old gentleman was finally relieved of these 
annoyances by a band fastened under the chin. In such a case, an ap- 
paratus constructed after the some plan as my lower jaw apparatus might 
perhaps serve a useful purpose. 

§ 3. Conditions of the Jaw simulating Luxations. 

There is a condition of the temporo-maxillary articulation called by 
Sir Astley Cooper " subluxation of the jaw," in which it is assumed that 
the condyles slip before the anterior margins of the interarticular carti- 
lages, and thus for the time render the jaw immovable. No positive evi- 
dence, however, has ever been presented, either by Sir Astley or others, 
that any such derangement of the joint apparatus does actually take place, 
the opinion being based, not upon dissections, but only upon the symp- 
toms which are known to accompany the accident. It is quite probable 
that this explanation of the phenomena in question is the true one, yet it 
is not impossible that, in some rare cases, it has no relation whatever to 
the interarticular cartilages, but that it indicates a true subluxation of the 
inferior maxilla upon the zygomatic eminences. 

It occurs mostly in young people, and in those of a feeble or scrofu- 
lous diathesis. Relaxation of the capsule, ligaments, and muscles about 
the joint may, therefore, be regarded as the principal predisposing cause. 
The exciting causes are generally yawning, or biting upon some very 
hard substance. 

The symptoms are a sudden arrest of the motions of the jaw, with 
the mouth about half open, the arrest of motion being accompanied or 
preceded generally with a sensation of slipping in one of the articula- 
tions. The chin is slightly inclined to the opposite side. The condyle 
may be felt somewhat advanced in its socket, and while it remains in this 
position the patient experiences some pain. 

In most cases the condyle resumes its place spontaneously, or after a 
slight lateral motion of the jaw ; but at other times it requires some little 
manual force to replace it. 

I have myself, during several years of my early life, while pursuing 
my studies at college, experienced this accident many times. It was 
peculiarly prone to occur in the morning, and it became necessary that I 
should eat with some care at my first meal. Sometimes the locking of 



CONDITIONS OF THE JAW SIMULATING LUXATIONS. 597 

the jaw was upon the right and sometimes upon the left side ; it was always 
slightly painful. Generally the condyle was made to fall into place by 
a voluntary lateral motion of the jaw, but occasionally I was obliged to 
press gently against the chin with my hand. I never adopted any meas- 
ures to remove the predisposition, but as I became older the annoyance 
gradually ceased. 

Benevoli, in a dissertation published at Florence, Italy, in the year 
1747, describes another condition very analogous to this which we have 
now described, but which evidently depended upon a contraction of the 
muscles. A priest, having opened his mouth very widely in gaping, 
found himself unable to close it. A surgeon who was called diagnosti- 
cated a dislocation of the jaw, and attempted to reduce it, but failing, 
Benevoli was called, who, observing " that the jaw was not absolutely 
immovable, that the articulations were not separated, and that the chin 
did not incline outwards or toward the sternum," concluded that it was 
only a contraction of the depressing muscles. He therefore prescribed 
fomentations and oily unctions. The same night the temporal muscles 
had acquired the size of a couple of eggs, from contraction, but the next 
day the patient could shut his mouth, and by the following day the tume- 
faction of the temporal muscles had also disappeared, and the restoration 
of the functions of the mouth was complete. 

Malgaigne, to whom I am indebted for the above case, relates two 
others, one in the person of the surgeon Mothe, and the other in a young 
man w T ho was suffering from paralysis and spasmodic contractions of the 
muscles. Mothe observes that it had occurred to him very often, and 
that it still continued to happen sometimes, that w r hen he gaped pretty 
widely, the genio-hyoid and mylo-hyoid muscles contracted with so much 
force as to render it impossible for him to close his mouth ; these muscles 
being thus in a state of cramp, their bellies became hard under the chin, 
and so painful that he was obliged immediately to press upwards against 
the under surface of the chin in order to oppose their action. This con- 
dition would last from one to three minutes, and was relieved, generally, 
by frictions made with the hand over the contracted muscles. Some- 
times he actually believed that the lower jaw T w T as dislocated, although 
the result always convinced him that it was not. 

Treatment. — In most or all of the cases of this peculiar derangement 
of the temporo-maxillary articulation, which have come under my notice, 
a spontaneous cure has been soon effected. It will be proper, however, 
in all cases, to instruct the patient to avoid using the jaw in a manner to 
produce the sensation of slipping ; and if the general health is impaired, 
to adopt suitable measures to improve his condition. Cold water affu- 
sions to the side of the face and jaw would seem also to be rational 
measures, and I have generally recommended their use. 



598 DISLOCATIONS OF THE SPINE. 



CHAPTER III. 

DISLOCATIONS OF THE SPINE. 

Delpech and Abernethy denied the possibility of a dislocation of the 
spine, either in the cervical, dorsal, or lumbar region, without the con- 
currence of a fracture. 

Says Sir Astley Cooper: " I have never witnessed a separation of 
one vertebra from another through the intervertebral substance, without 
fracture of the articular processes; or, if those processes remain un- 
broken, without a fracture through the bodies of the vertebras." He 
would not, however, be understood to deny the possibility of a disloca- 
tion of the cervical vertebrae, their articular processes being placed more 
obliquely than those of the other vertebras. 

The accident is, no doubt, exceedingly rare, at least without the com- 
plication of a fracture, and it is not improbable that the actual number 
is smaller than the reported examples would indicate. Those who make 
autopsies do not always perform their duties with that exact fidelity 
which might be necessary to determine so nice a point as a fracture of 
an oblique process, and it is quite likely that the circumstance may have 
been overlooked in some cases ; but a considerable number of well- 
authenticated examples of simple dislocations of cervical vertebras have 
accumulated within the last fifty years. The reported examples of 
simple dislocations of the other vertebras are not so numerous, nor as 
well attested. 

The causes are in general the same with those which produce fractures 
of the vertebras, such as falls upon the head, feet, or back, and violent 
flexions of the spine backwards or to the one side or the other. 

Several examples are recorded of "spontaneous" dislocations, the 
result of some morbid changes in the bones or in the ligaments of the 
spinal column ; which accidents seem to belong more properly to general 
treatises upon surgery. 

The symptoms, also, partake of the same general character with frac- 
tures; the accident being accompanied with more or less complete 
paralysis of those portions of the body which receive their nervous 
supply from below the point at which the dislocation has occurred ; the 
spinal column presenting at the seat of displacement an angular projec- 
tion or some form of irregularity ; and the distortion being attended 
with pain, especially when an attempt is made to move the body. 

In very many cases the symptoms are so nearly like those presented 
in a case of fracture, that the diagnosis is rendered exceedingly difficult. 
The presence or absence of crepitus may aid in the diagnosis, and yet 
it is well understood that this symptom is often absent in simple frac- 
tures, and that it may be present in all those examples of dislocation 



DISLOCATIONS OF THE LUMBAR VERTEBRA. 599 

which are accompanied with a fracture of an oblique process, or of any 
other portion of the vertebrae, which class of examples constitutes a large 
majority of the whole number. 

There is usually present, however, in the dislocation, whether partial 
or complete, a peculiar fixedness or rigidity of the spine, which serves 
to distinguish this accident from a fracture of the spine as plainly as the 
preternatural rigidity of the limb in dislocations of the long bones, serves 
to distinguish these accidents from fractures of the same bones. The 
head or upper portion of the spinal column is bent forwards, or back- 
wards, or more commonly to one side, and in this position it remains 
immovably fixed until the reduction is accomplished. Sometimes, also, 
the surgeon may feel distinctly the lateral deviation of the spinous pro- 
cess, and, in the neck, the transverse processes become an important 
guide in the diagnosis. . 

After these few general remarks, I shall proceed to speak of disloca- 
tions of the spine in the same order in which I have treated of fractures 
of the spine. 

§ 1. Dislocations of the Lumbar Vertebrae. 

Sir Astley Cooper plainly intimates that he does not believe a dislo- 
cation can occur in either the dorsal or lumbar region without the 
concurrence of a fracture, and Boyer affirms positively that it is " en- 
tirely impossible." 

Without wishing ourselves to insist upon the actual impossibility of 
these accidents, we are prepared to affirm that no well-authenticated 
case has yet been reported ; at least of a complete dislocation, unaccom- 
panied with a fracture of the articulating apophyses. We can even 
conceive it possible that a lumbar vertebra may be dislocated forwards 
or backwards, and that a dorsal vertebra may be dislocated laterally, 
without a fracture ; yet we hardly think either of these events probable. 
What we urge, however, is that no evidence appears to be furnished 
that such a dislocation has actually occurred. 

Cloquet mentions the case of a " tiler" who fell from the roof of a 
house backwards, and dislocated one of the lumbar vertebrae. This 
patient lived many years after the accident, and at the autopsy it was 
found that the second lumbar vertebra had been luxated to the right by 
a movement of rotation about the left articular process, the two oblique 
processes of the left side preserving their connection, while those of the 
right were separated quite half an inch. The right vertebral plate was 
broken, and the canal of the vertebra was thus thrown open and 
widened. 1 

Dupuytren says that a man was crushed by the falling of a bank of 
earth upon his loins, when in the act of bending forwards. On the 
third day he was brought to Hotel Dieu, when it was observed that his 
lower extremities were completely paralyzed ; and that there existed in 
the upper part of the lumbar region a hard tumor, by pressure upon 
which a crepitus was manifest. A second tumor could be distinctly felt 

1 Cloquet, Malgaigne, from Journ. des Difformites de Maison., torn. i. p. 453. 



600 DISLOCATIONS OF THE SPINE. 

in front through the abdominal parietes, and the length of the spine was 
evidently diminished. This man died on the sixth day from a gradual 
asphyxia. When the body was examined it was found that the last 
dorsal and first lumbar vertebrae had been pushed forwards more than 
one inch, lacerating the spinal marrow, breaking the transverse and 
oblique processes of the last dorsal and first two lumbar vertebrae, and 
tearing off a small fragment of the body of one of the vertebrae where 
the intervertebral substance adhered to it. 1 

These are all the cases of dislocation of the lumbar vertebrae of which 
I am able to find any record. Both were accompanied with fractures. 
In neither case was any attempt made to reduce the dislocations. In 
the second, it is scarcely probable that any means could have been em- 
ployed which would have succeeded in restoring the bones to their 
places ; nor is it probable that if the bones had been restored to place, 
the patient would have survived the accident a day longer, probably not 
so long. The cord was greatly lacerated, and the diaphragm torn up 
and displaced, rendering a recovery almost impossible. 

In the first example, where the dislocation was less complete, and the 
complications less grave, could reduction have offered any reasonable 
chance for relief? By extension, combined with a movement of rotation 
in a direction opposite to that in which the displacement had taken 
place, it is possible that a reduction might have been accomplished. 
The attempt certainly would have been justifiable ; but since the man 
lived " many years" without the reduction, it is doubtful whether the 
result of a reduction would have been more fortunate. 

§ 2. Dislocations of the Dorsal Vertebrae. 

Malgaigne enumerates twelve examples of dislocations of the dorsal 
vertebrae. I have found reported by American surgeons, at dates too 
recent to have been included in his analysis, two other examples ; but 
of this number only three are claimed to have been simple dislocations, 
unaccompanied with fracture. One of the fourteen was a dislocation of 
the fifth dorsal vertebra upon the sixth, one of the eighth, two of the 
ninth, five of the eleventh, and five of the twelfth; the relative fre- 
quency of their occurrence in the different vertebrae corresponding with 
the observation of Weber, as to the points of the spinal column which 
allow of the greatest freedom of motion, and are consequently most liable 
to dislocations. The direction of the displacement in ten cases was 
observed to be six times forwards, twice backwards, and twice to the one 
side. 

Two of those which were unaccompanied with fracture, occurring 
respectively in the tenth and sixth dorsal vertebrae, were examples of 
a dislocation forwards, and the third, belonging to the ninth vertebra, 
was a dislocation backwards. A lateral luxation without fracture has 
not been recorded. It is worthy of remark, also, that these three exam- 
ples, being all which our science up to this moment possesses, have hap- 
pened in the experience of the same surgeon. 2 

1 Dupuytren, Injuries and Dis. of Bones, Syd. ed., p. 340. 

2 Melchiori, Gaz. Medica, stati sardi, 1850. 



DISLOCATIONS OF THE DORSAL YERTEBRJ. 601 

A moment's consideration of the anatomy of these processes will 
render it apparent that even a partial luxation forwards without a frac- 
ture of the oblique apophyses is impossible ; and that in the direction 
backwards the luxation can only occur to the extent of about one-quarter 
of an inch, constituting only a species of articular diastasis, without 
breaking off the articulating apophyses of the lower corresponding ver- 
tebra. The first two examples, therefore, notwithstanding they have 
been received without question by Malgaigne, I shall unhesitatingly re- 
ject. The third, which alone carries evidence of its having been cor- 
rectly reported, and which was only a partial dislocation, is related as 
follows: "A mason, having fallen from a height in such a manner that 
the lower part of his back struck upon the angle of the upper step of a 
ladder, died on the following day. After death it was observed that the 
spinous processes of the dorsal vertebras were prominent down to the 
tenth ; and that the tenth process with all of the processes below were 
depressed. It was also noticed that this depression, very marked when 
the trunk was thrown backwards, gradually diminished and finally dis- 
appeared altogether when the body was bent forwards. On removing 
the soft parts it was found that the ligaments were extensively torn asun- 
der and detached, so as to permit the articulating apophyses of the tenth 
vertebra to be carried into contact with the back of the ninth. The 
spinal marrow had undergone no visible alteration." 1 

Malgaigne thinks he has once observed the same thing on a living sub- 
ject, and that by simply bending the body forwards he accomplished the 
reduction and effected a perfect cure, except that a slight curvature re- 
mained at the point of injury. 

Among the cases reported as having been complicated with fracture, 
the following example, reported by Dr. Graves, of New Hampshire, to 
Dr. Parker, of this city, possesses unusual interest :■ — ■ 

On the second day of January, 1852, a man, set. 25, was struck on 
the back while in a stooping posture by a falling mass of timber, causing 
a dislocation of the last dorsal upon the first lumbar vertebra. His 
lower extremities were completely paralyzed, and priapism continued for 
several hours. The surgeon determined to make an attempt at reduction, 
and for this purpose he placed the patient upon his face, and secured a 
folded sheet under his armpits and another around his hips, directing 
four strong men to make extension and counter-extension by these sheets. 
Chloroform was administered, and when the patient was completely under 
its influence the extending and counter-extending forces were applied, 
and in a few minutes the vertebrse glided into place with a distinct bony 
crepitus. The restoration of the line of the vertebral column was found 
to be nearly but not quite perfect. 

On the sixteenth day he began to have slight sensation in his feet, and 
at the end of six or eight weeks he was able to control the evacuations 
from the bladder and rectum. Several months later he had recovered 
so completely as to walk with only the aid of a cane. 2 

I know of only one similar case. Rudiger has published an account 



39 



1 Melchiori, loc. cit. 

2 Graves, N. Y. Journ. Med., March, 1852, p. 190. 



602 DISLOCATIONS OF THE SPINE. 

of a dislocation obliquely backwards and to the right side, which occurred 
at the same point in the spinal column. The subject was a musketeer, 
who had been struck upon his back by a falling wall which he was endeav- 
oring to pull down.. Rudiger laid him upon his belly, and by the assist- 
ance of others he was able, but not without causing pain, to reduce the 
bones. Immediately, however, when the extension was discontinued, the 
action of the muscles caused the displacement to recur. The surgeon 
then directed four men to make extension, while another man retained 
the bones in place by pressing upon them with his hands. After several 
hours this method of pressure was replaced by a board underlaid with 
compresses and sustaining a weight of more than fifty livres. On the 
following day it was found sufficient to bind compresses over the project- 
ing bone, and in this condition the patient remained fifteen days ; during 
all of which time he lay upon his belly with his shoulders more elevated 
than his pelvis. On the twentieth day he could lie upon his back, and 
in about six weeks he was so completely restored as to be able to pur- 
sue his trade as before I 1 This is certainly a very extraordinary case, 
whether considered in reference to the means employed to restore the 
bones to place, or to its results ; and if the statements are to be received 
at all, it must be with some hesitation and allowance. 

On the other hand, we are able to present at least one example in 
which, although no reduction has been accomplished, the patient has 
survived the accident many years ; yet it must be admitted that his 
recovery is far from having been as complete as in the two cases just 
mentioned. 

Joseph Stocks, set. 11, in the spring of 1828, was crushed under the 
body of an ox-cart in such a manner as to produce a dislocation of the 
last dorsal from the first lumbar vertebra, causing immediately almost 
complete paralysis of all the parts below. This young man was seen 
by Dr. Swan, of Springfield, Mass., in the summer of 1834, at which 
time he was occupied as a portrait-painter. His lower extremities re- 
mained paralyzed and of the same size as at the time of the receipt of 
the injury. He was unable to sit erect, owing to the mobility of the 
spine at the seat of dislocation, and he had therefore lain constantly upon 
his side. The upper portion of his body was well developed, and his 
intellectual faculties were of a high order. 2 

It is not, however, with a life of perpetual deformity that the two ex- 
amples of reduction already described are to be contrasted. A result 
so fortunate as this, where the bones remained unreduced, is unique ; in 
all the other cases reported the patients died miserably after periods 
ranging from a few days to one year or a little more. 

Charles Bell has related the case of an infant who was run over by 
a diligence, and w r ho died thirteen months after the accident. On exam- 
ination after death, the last dorsal vertebra was found to be completely 
luxated backwards and to the left, upon the first lumbar vertebra. 3 

With these facts before us, I think we cannot hesitate, when the nature 

1 Rudiger, Journ. de Chir. de Desault, torn. iii. p. 59. 

2 Swan, Bost. Med. and Surg. Journ., vol. xxii. p. 102, March, 1840. 
5 Charles Bell, on Injuries of the Spine, 1824. 



OF THE SIX LOWER CERVICAL VERTEBRAE. 603 

of the accident is fully made out, and especially when the dislocation 
has occurred in the lower dorsal vertebrae, to attempt the reduction by 
forcible extension, united with judicious lateral motion, or with a certain 
amount of direct pressure upon the projecting spines. 

3 3. Dislocations of the Six Lower Cervical Vertebrae. 

It is much more common to meet with simple luxations of the vertebrae 
of the neck uncomplicated with fractures, than of either of the other ver- 
tebral divisions. This is doubtless owing to the greater extent of motion 
which their articulating surfaces enjoy. 

They may be dislocated forwards or backwards. The forward luxation 
may be complete or incomplete ; with both sides equally advanced (," bi- 
lateral" of Malgaigne), or one of the articulating apophyses may be 
dislocated forwards, holding the opposite apophysis in its place ( a uni- 
lateral" of Malgaigne). 

Schranth 1 has collected twenty-four examples of luxation of the cer- 
vical vertebrae, of which four are recorded as dislocations forwards, two 
back, and six to the one side or the other. Three of this number were 
dislocations of the atlas, two were dislocations of the second vertebra, 
five of the fourth, tw r o of the fifth, two of the sixth, and one of the 
seventh. In the other cases the seat was not stated. 

Malgaigne has brought together forty-five examples ; of which twenty- 
one were complete forward luxations, nine incomplete fonvard luxations, 
nine unilateral and forwards, and four were backward luxations. Three 
were dislocations of the second vertebra upon the third, four were dis- 
locations of the third vertebra, ten of the fourth, eleven of the fifth, 
fifteen of the sixth, and two of the seventh. 2 

The bilateral forward luxations are generally caused by a fall upon 
the top and back of the head, or upon the top of the head while the neck 
is very much flexed forwards. The unilateral is caused generally by a 
direct blow upon the back of the neck, the blow being probably directed 
somewhat to one side or the other. The number of backward luxations 
which have been reported are too few to enable us to indicate very accu- 
rately the general causes, but it seems probable that they are most often 
occasioned by a fall upon the fore and top part of the head, received 
while the neck is bent forcibly back. 

In dislocations of the cervical vertebrae forwards the head is usually 
depressed toward the sternum, in dislocations backwards the head is 
thrown back, and in unilateral dislocations the head is turned over one 
of the shoulders. Neither of these malpositions of the head is uni- 
formly present in these several dislocations, and indeed not unfrequently, 
especially in case the system is greatly shocked by the accident, the 
head and neck assume a preternatural mobility, and may be turned 
easily in any direction. 

The spinous process, unless the patient is very fleshy or considerable 
swelling has supervened, can easily be felt, and its deviations to the 

1 Schranth, Amer. Journ. Med. Sci., May, 1848, from Archiv fur Phys. Heilkunde. 

2 For additional cases see Dublin Journ. Med. Sci., March, 1879, p. 260. 



604 DISLOCATIONS OF THE SPINE. 

right or to the left, forwards or backwards, furnish us with the most 
valuable and important sign of the dislocation. Even the transverse 
processes may be felt sometimes, especially in the upper part of the 
neck, with sufficient' distinctness to render them useful in the diagnosis. 

To these circumstances we may add paralysis of the body below the 
seat of injury, with pain and swelling at the point of dislocation. In 
some cases also the patient has himself distinctly felt a cracking or 
sudden giving way in the neck at the moment of the accident. 

Prognosis. — The complete bilateral luxations, whether backwards or 
forwards, have in most cases terminated fatally within a short time, gen- 
erally within forty-eight hours. Unilateral luxations are less speedy in 
their results, but when the dislocation remains unreduced, death gen- 
erally takes place in a month or two. Lente relates a case of incom- 
plete dislocation of the fifth cervical vertebra backwards, unaccompanied 
with fracture, which accident the patient survived five days. 1 A patient 
of Roux's lived eight days ; but in the case of a second patient men- 
tioned by Lente, with a complete luxation, without fracture, of the fifth 
vertebra, the patient survived the injury only two hours. 2 

On the other hand, occasional examples are presented of partial or 
complete recovery with the luxation unreduced. 

Horner, of Philadelphia, presented to the class of medical students of 
the University of Pennsylvania, in 1842, a lad, set. 10, who had fallen a 
distance of twenty feet, alighting upon his head. He was found sense- 
less and motionless, with his head bent under his body. He gradually 
recovered from the shock, but his neck was stiff, distorted, and motion- 
less, his face being inclined downwards to the right side. Two days 
after, his " common and accurate perceptions returned, but he was 
affected for some time with tingling and numbness in his left arm." 
When presented to the class the transverse processes, from the fifth 
upwards, were about half an inch in front of those below, showing that 
the left oblique process of the fourth was dislocated forwards upon the 
fifth. The rotary motions of the neck could now be executed to some 
extent, but much more freely to the right than to the left. Professor 
Horner refused to make any attempt to reduce the dislocation. 3 

Dr. Purple, of New York, has reported a case of what was called a 
dislocation of the fifth and sixth cervical vertebrae, producing complete 
paralysis of the lower part of the body, in which the patient survived 
the accident many years ; but his lower extremities were so useless and 
cumbersome as to induce him, in the year 1851, six years after the injury 
had been received, to submit to the amputation of both at the hip-joint. 
In 1852, having become very intemperate, he died, but no autopsy was 
obtained, so that the exact character of the injury was never ascertained. 4 
Sanson, of Paris, has reported also a case which came under his observa- 
tion at Hotel Dieu, of dislocation of the " third cervical vertebra back- 
wards," from which, although unreduced, the patient partially recovered. 
.The character of this accident was not much better determined; for, 

1 Lente, New York Journ. Med., May, 1850, p. 284. 2 Lente, ibid., p. 397. 

3 Horner, Amer. Journ. Med. Sci., April, 1843, from Med. Exam. 

4 Purple, New York Journ. Med., May, 1853, p. 319. 



OF THE SIX LOWER CERVICAL VERTEBRAE. 605 

although he felt a severe and sharp pain at the moment of the injury, 
which was greatly aggravated by motion, and his head was bent forwards 
and to the left, " the chin being fixed on the upper part of the sternum," 
there was no paralysis of either the motor or sentient nerves. After 
the lapse of about four months he left the hospital, still unable to lift his 
chin more than four inches from the sternum ; after which he resumed 
his usual occupations, suffering no further inconvenience than what was 
occasioned by the unnatural position of his head. 1 Notwithstanding the 
authoritative testimony of Sanson that this was a dislocation backwards, 
one cannot avoid the conclusion that it was either a unilateral subluxa- 
tion, or perhaps a mere diastasis of the articulation, or else that it was 
an example of sprain of the muscles, and consequent contraction of one 
set, or paralysis of the opposing set of muscles. It is certain that it 
was not a complete luxation ; nor, since there was no paralysis of the 
body below the point of injury, can it be properly made use of as an 
argument for non-interference where such paralysis does actually exist. 

Let us see now what encouragement an attempt at reduction may offer, 
in a case which presents so little ground of hope where the reduction is 
not accomplished. 

Dr. Spencer, of Ticonderoga, 1ST. Y., relates that a man, get. 50, fell 
backwards from a board fence, striking upon the superior and anterior 
portion of his head, dislocating the second from the third vertebra of 
the neck. His head was thrown back so far as to prevent his seeing 
his own body, and all below the injury was completely paralyzed. 
Repeated attempts were made to reduce the dislocation, "but the trans- 
verse processes had become so interlocked that every effort proved 
abortive," and he died forty-eight hours after the injury was received. 2 
Gaitskill also attempted reduction in a case of dislocation of the seventh 
cervical vertebra, but failed. 3 Boyer failed in two cases. It is related 
by Petit Radel, that a young patient at La Charite expired in the 
hands of the surgeons, upon such an attempt being made a few days 
after the accident ; 4 and Dupuytren says " the reduction of these dislo- 
cations is very dangerous, and Ave have often known an individual perish 
from the compression or elongation of the spinal marrow which always 
attends these attempts." 

Dr. Schuk, of Vienna, relates that a man, set. 24, while engaged at 
his work on December 5, 1838, twisted his head suddenly round, in 
consequence of one of his companions roaring into his ear, when he in- 
stantly felt something give way in his neck, and found it impossible to 
move his head. Next morning his head was turned to the right and 
bent down toward the shoulder. Every attempt to move his head 
caused great pain. He complained of weakness in his right arm, but 
all the other functions of his body were perfect. An attempt was im- 
mediately made to reduce the dislocation by lifting him by the head, 
but without success. On December 7th, the weakness and numbness 

1 Sanson, Amer. Journ. Med. Sci., Feb. 1836, p. 514, from Gaz. des Hopitaux. 

2 Spencer, Boston Med. and Surg. Journ., vol. xv. No. 11. 

3 Graitskill, London Repository, vol. xv. p. 282. 

4 Petit Radel, Note to Boyer, Malad. Chir., vol. v. p. 118. 



606 DISLOCATIONS ■ OF THE SPINE. 

of the right arm had increased, and the attempt to reduce the bones 
was renewed. The patient was laid horizontally upon a bed, and ex- 
tension made from the chin and occiput while counter-extension was 
made from the shoulders. The force thus employed was gradually in- 
creased until the patient and assistant felt a snap as of two bones meet- 
ing, when it was found that the head was restored to its natural position, 
and the power of moving it had returned. The next day his arm was 
more powerless than before, and on the following day he had vertigo, 
but these symptoms soon yielded to copious bleedings, and he left the 
hospital cured on the 13th. 1 

Dr. Hickerman, of Ohio, has reported also, in the Ohio Medical 
Journal, a case of dislocation of one of the cervical vertebrae, the origi- 
nal account of which I have not seen, but only an abridged statement 
published in the Buffalo Medical Journal. By exploring the pharynx 
a prominence was felt opposite the junction of the fourth and fifth cer- 
vical vertebrae ; and the action of the heart was barely perceptible. 
Seizing the patient's head under his left arm, Dr. Hickerman in this 
manner made traction, while with the index finger of the right hand 
in the patient's throat, he made firm pressure obliquely upwards, back- 
wards, and to the left ; after continuing the pressure for about forty or 
fifty seconds, the part against which the finger was placed gradually 
yet quickly receded in the direction in which the pressure was made, 
and instantly, as quickly indeed as the act could be possibly executed, 
the patient opened her eyes, and natural respiration was established. 
She then also immediately became conscious of what was transpiring 
about her, and signified by signs, for she was yet unable to speak, that 
she had suffered pain in the epigastrium. Complete recovery took 
place. 2 

Schranth received under his care a patient who had a luxation of the 
" right transverse apophysis" of the fourth cervical vertebra, without 
lesion of the spinal marrow, which he reduced on the seventh day. 
The first attempt was unsuccessful ; but the second, made with great 
caution, by the aid of four assistants, three of whom pulled the head 
upwards while the fourth pressed with his whole weight upon the 
shoulders, was completely successful. During the time that the trac- 
tion was being made, the head was occasionally rotated slightly and 
moved laterally, and at the same moment the surgeon pushed firmly 
against the displaced apophysis. The reduction was attended with 
" various distinct crackings in the neck," which were loud enough to 
be heard. After some days of repose he resumed his occupation, no 
stiffness remaining in the movements of the neck. 3 

Dr. Edward Maxson, of Geneva, N. Y., was called, on the 28th of 
Oct. 1856, to see a child about nine years old, who had met with a sim- 
ilar accident about forty hours before, namely, a dislocation of the right 
articulating apophysis of the fifth or sixth cervical vertebra, occasioned 
by suddenly turning her head around while at play. She at first com- 

1 Schuk, Amer. Journ. Med. Sci., July, 1841, p. 207. 

2 Hickerman, Buf. Med. Journ., vol. x. p. 702, April, 1855. 

3 Schranth, Amer. Journ. Med. Sci., May, 1848. 



OF THE SIX LOWER CERVICAL VERTEBRA. 607 

plained only of pain and inability to straighten the neck ; but whenever 
moved she became faint and irritable. A short time before the surgeon 
was called, the mother had, in attempting to move her in bed, turned the 
face a little more to the left, when a severe convulsion immediately en- 
sued. On examining the neck, Dr. Maxson discovered the displacement 
of the transverse process. Having advised the parents of the danger 
necessarily incident to an attempt at replacement, and of the probable 
consequences of its being permitted to remain as it was, they consented 
that the trial should be made. "I grasped the head," says Dr. Max- 
son, " with both hands, and proceeded according to Desault's method, 
only I first carried or turned the face very gently a little further toward 
the left shoulder, to, if possible, disengage the process ; then lifting or 
extending the head, I turned the face very gently toward the right 
shoulder, when the difficulty was at once overcome, and she exclaimed : 
6 1 can move my eyes.' Her countenance soon acquired a more natural 
appearance ; the faintness passed off; she rested quietly through the 
night ; had no return of the difficulty, and needed only an emollient ano- 
dyne to soothe the irritation and slight swelling which remained at the 
point of injury." 1 

Dr. Berthold, of Nuremberg, reduced a dislocation of one of the ob- 
lique processes of the sixth vertebra in a boy, get. 19, by extension with 
his hands and rotation. 2 

Dr. Wm. J. Morton, of New York, has reported a case of dislocation 
of the fifth oblique process in a boy twelve years old, reduced after the 
lapse of one week, by suspension of the head between the hands and 
rotation. 3 

Dr. John A. Wyeth, of this city, relates a case of dislocation of the 
right articular process of the fourth vertebra forwards, from muscular 
action, in the person of a lady who had turned her head strongly to the 
left side. Her head became fixed immovably ; there was great pain at 
the point of this articulation ; oppressed breathing and a numbness ex- 
tending down the arm of the same side. Dr. Wyeth was immediately 
summoned, and attempted to rotate the head into position, but was una- 
ble to do so. He then seized the head and rotated it slightly to the left, 
then made strong extension and rotated to the right, when the head 
returned to and retained its natural position. During the next two days 
there was considerable pain along the spinal cord and in the right arm. 
Three months after the accident she was perfectly well. 4 

Rust, 5 Wood, of this city, 6 and others, have seen and reported similar 
cases attended with like success. 

So far the cases of successful reduction which we have described are 
examples of dislocation of only one of the articulating apophyses, and 
they have been sufficiently numerous and successful to establish the value 
of attempts at reduction. We have now to relate a case in itself unique, 

1 Maxson, Buffalo Med. Journ., Jan. 1857, p. 476. 

2 Berthold, Month. Ab. Med. Sci., Jane, 1875. 

3 Morton, Med. Rec, Oct. 4, 1879. 

4 Wyeth, Hosp. Gaz., N. Y., Aug. 1879. 

5 Rust, Chelius, note by South. 

6 Wood, New York Journ. Med., Jan. 1857, p. 13. 



608 DISLOCATIONS OF THE SPINE. 

namely, a successful reduction of a dislocation of the fifth cervical ver- 
tebra, in which both apophyses appear to have been thrown forwards. 
It occurred in the practice of Dr. Daniel Ayres, of Brooklyn, N. Y., and 
will be best understood by a reproduction of his own published account 
of the case : — 

" E. K., the subject of this accident, was a laboring man, thirty years 
of age, tall and muscular, but not fat, with a neck longer than the aver- 
age among men of equal height. On the evening of the 2d of October 
he became intoxicated ; was brought home insensible, and did not recover 
from the combined effects of the shock and his libations until the follow- 
ing morning, when he was supposed by his wife to be laboring under 
cold and a stiff neck. She made some domestic applications to the 
affected part, and administered a dose of cathartic medicine. When it 
was thought sufficient time had elapsed without obtaining relief, he was 
seen by Dr. Potter, of this city, and afterwards by Dr. Cullen, both of 
whom recognized a condition which was not only very unusual, but one 
which they had never before observed. I was then requested to examine 
the case, which I did on the ninth day after the accident. With some 
assistance and great personal effort, he was able to get out of bed, 
moving very slowly and cautiously. Desiring to expectorate, he was 
obliged to get doivn on his hands and knees, which he accomplished with 
the same deliberation. When seated in a chair, the head was thrown 
back and permanently fixed ; the face turned upwards with an anxious 
expression. The anterior portion of the neck, bulging forwards, was 
strongly convex, rendering the larynx very prominent. The integu- 
ments of this region were exceedingly tense and intolerant of pressure. 
The posterior portion of the neck exhibited a sharp, sudden angle at the 
junction of the fifth and sixth cervical vertebrae, around which the integ- 
uments lay in folds. It was difficult to reach the bottom of this angle 
even with strong pressure of the fingers, and of course the regular line 
formed by the projecting spinous processes was abruptly lost. He com- 
plained of intense and constant pain at this point, which was neither 
relieved nor aggravated by pressure. With difficulty he swallowed 
small quantities of liquid, pausing after each effort, and could not be 
induced to take solid food, since the first attempt to do so after the accident 
was followed by violent paroxysms of coughing and choking. His 
breathing was obstructed and somewhat labored, being unable fully to 
clear the bronchi of their secretion. This, however, seemed rather an 
effect of the tense condition of the soft parts of the neck, than the result 
of pressure upon the spinal cord, since he presented no evidence of paral- 
ysis, either of motion or sensation, in parts below the neck. The sterno- 
cleido-mastoid muscles of both sides were felt quite soft and relaxed. 

" But one conclusion could be formed upon this state of facts, to wit : 
that the oblique processes of both sides were completely dislocated. 
The marked rigidity of the head seemed to preclude the probability of 
fracture through the vertebral bodies, and although the cartilage might 
be separated anteriorly, yet the body not pressing backwards sufficiently 
to produce paralysis of the cord, it was hoped that the posterior verte- 
bral ligament remained uninjured ; it was, therefore, determined to make 
an effort at reduction on the following day. In addition to those origin- 



OF THE SIX LOWER CERVICAL VERTEBRAE 



609 



ally connected with the case, I am under obligations to Drs. Ingraham, 
Turner, Palmedo, Gr. D. Ayres, and a number of other medical gentle- 
men, who were present by invitation, all of whom confirmed the diag- 
nosis, and rendered efficient services. 

" The patient was placed upon a strong table, in a recumbent position, 
with a pillow resting under the shoulders, the head being supported by 
the hand during the administration of chloroform, of which an ounce was 
given before anaesthesia ensued. Counter-extension being made by two 
folded sheets placed obliquely across the 
shoulders and properly held, the head 
was grasped by one hand placed under 
the chin, the other over the occiput, and 
by steadily and firmly drawing the head 
directly backward, and then upwards, an 
attempt was made at reduction, but failed 
for want of sufficient power. Dr. Ingra- 
ham was then requested to place his hands 
immediately over my own in the same 
position as before, and steady traction 
was again made in the same direction. 
Our united strength was required in 
drawing the head backwards and upwards 
to dislodge the superior oblique processes 
from their abnormal position. When this 
was felt to be yielding by Dr. Cullen 
(who kept one hand constantly at the 
seat of dislocation), Dr. Potter was di- 
rected to place his hands under our own, 
still in position, and assist in bringing 
the head forwards ; at the same time the 
chest was depressed toward the table. 
The bones were distinctly felt to slip into 
their places ; the line of the spine was 
instantly restored, the head and neck as- 
suming their natural position and aspect. As soon as the patient became 
conscious, he expressed himself ignorant of what had taken place, but 




case of bilateral dislocation of the 
fifth cervical vertebra. 



free from pain, and, in his own language, ' all 



right.' 



A bandage was 



arranged to support the head and keep it bent forwards. He had an 
anodyne for two nights following, after which no further treatment was 
necessary, and at the end of one week he had complete control over the 
movements of the head and neck. Beyond the debility and emaciation 
immediately dependent upon protracted fasting and loss of rest, he has 
experienced no uneasiness since the operation. His appetite is now good, 
and all the functions perform their duty normally. In a subsequent 
inquiry, to determine, if possible, the cause of the accident, he states 
that he distinctly recollects going into a store in Atlantic Street, near 
the ferry, and there having angry words with an acquaintance ; that he 
left the store, and was proceeding up the street (wdiich is here a rather 
steep ascent), when he was violently struck from behind, over the lower 
portion of the neck. He likewise remembers falling forwards, and strik- 



610 DISLOCATIONS OF THE SPINE. 

ing against some object, but does not know what it was, nor what took 
place until the following morning." 1 

§ 4. Dislocations of the Atlas. 

Surgeons have met with several forms of displacement between the 
atlas and axis. First, a forced inclination forwards of the atlas upon the 
axis ; in consequence of which the body or anterior arch of the atlas is 
made to recede from the odontoid process, and the transverse ligament 
glides upwards without breaking ; so that the extremity of the odontoid 
process comes to occupy a position underneath or behind the ligament, 
and thus presses upon the cord. It is apparent also, that this form of 
displacement cannot occur without a rupture of the vertical ligaments 
which bind the transverse ligaments to the axis ; nor without a separation 
of the atlas from the axis posteriorly and a -rupture of the posterior atlo- 
axoidean ligament. Second, a similar inclination of the atlas, accompa- 
nied with a rupture of the transverse and superior vertical ligaments, in 
consequence of which also the odontoid process is allowed to fall upon 
the cord. Third, the atlas in the same position, with the odontoid pro- 
cess broken at its base. Fourth, the atlas displaced directly forwards or 
backwards. Fifth, a displacement of only one articular process in a 
direction forwards ; and sixth, a displacement of one articular process 
forwards, and of the other backwards. 

We have already, when speaking of fractures of the atlas, or of the 
atlas and axis together, called attention to several examples of that form 
of the dislocation which is accompanied with a fracture of the odontoid 
process. The other forms of dislocation are characterized by so few 
symptoms peculiar to themselves, or which can be regarded as diagnostic 
and not already sufficiently studied in connection with other dislocations 
of the neck, that we shall not deem it necessary to do more than remind 
our readers, that if permitted to remain unreduced a speedy and fatal 
issue is inevitable, and to point them to some examples of recovery, 
after reduction has been fortunately accomplished. These may suffice 
to show that Dupuytren was in error when he declared that such acci- 
dents where wholly beyond the resources of our art. 

An old man received upon his head a bundle of hay cast from the top 
of a wagon. He fell with his head bent forwards so that his chin touched 
the top of the sternum, and in this position it remained immovably fixed ; 
all the other portions of his body preserved their natural functions. A 
surgeon, who was indeed the father of Malgaigne, being called, assured 
the patient, that unless he could give him relief he certainly would die ; 
but that inasmuch as the attempt might itself prove fatal, he ought at 
once to put in order his affairs. Accordingly the man partook of the 
sacrament ; then the surgeon seated him upon the ground, and placing 
himself at his back with his knees resting upon his shoulders for the pur- 
pose of making counter-extension, and with a towel brought over his own 
shoulders and under the chin of the patient for extension, he proceeded 
to act upon the neck in the direction of the axis of the spine. The efforts 

1 Ayres, New York Journ. Med., Jan. 1857, p. 9. 



DISLOCATIONS OF THE ATLAS. 611 

were long and painful ; but at last, while the head was lifted as far as 
possible, it was suddenly drawn backwards, and immediately it resumed 
its natural direction. Absolute quietude was enjoined, and the patient 
recovered in a short time and without any accident. 

This patient was seen two years after by the younger Malgaigne, at 
which time do trace of the accident remained, except an impossibility of 
turning the head to the right or to the left. 

Another example is related by Ehrlich,but in this case the dislocation 
was backwards. A young man, set. 16, while carrying a sack of flour 
up a ladder, fell backwards, and the sack falling over upon his face and 
head came to the ground before him. He was found lying with his head 
thrown back and to the right, the head resting upon the scapula of this 
side, but having so completely lost its " solidity" that by its own weight 
it would fall from one side to the other. On the front and left side of 
the neck there existed a prominence supposed to be formed by the atlas ; 
the patient was unconscious; the pulse was scarcely perceptible, and the 
whole body was suffering under paralysis. Ehrlich directed the shoulders 
to be held by one assistant, and the head to be drawn upon by another, 
while he pressed with his own hands forcibly upon the displaced atlas 
from behind. After several fruitless attempts, the reduction took place, 
accompanied with a sound distinctly audible to all of the assistants ; the 
head resumed its position firmly, and the arms began to move. The head 
was afterwards maintained in place by a bandage. The cure proceeded 
rapidly, and after a time no trace of the injury remained but a disagree- 
able tension in the nape of the neck whenever he moved his head briskly 
to the one side or the other. 1 

Uhde, Wagemann, and Boettger, of Braunschweig, report a case of 
'bilateral dislocation of the atlas, in which the right inferior articular 
process of the atlas was displaced forwards, in front of the correspond- 
ing superior articular surface of the axis, and the left inferior articular 
surface of the atlas backwards, behind the corresponding superior articu- 
lar surface of the axis, as shown by the position of the left transverse 
process of the atlas. " The patient, a roofer, fell from a height of thirty 
feet. The head was rotated upon all three of its axes, the right half of 
the face being turned forwards, the facial line forming an angle with the 
median line of the body, and the chin thrown forwards, and the forehead 
backwards. On the left side there was paralysis of the plexus pharyn- 
geus and the hypoglossal nerve ; on the right, simply paralysis of the 
glosso-pharyngeus. Careful anatomical and experimental research 
proved that the injuries of the nerves depended upon the dislocation. 
The nervus accessorius W. also suffered at a point corresponding to that 
on the hypoglossus, and to this the paralysis of the left velum palati, 
observed in the patient, was attributed; the plexus pharyngeus, of which 
the anterior branch of the accessorius forms a part, suffering by traction 
on the trunk of the nerve. The experiments also proved that, in this 
dislocation, the cord is not subjected to pressure, and that the vertebral 
artery is not injured. The dislocation was partially reduced two days 
after the accident by extension, extreme flexion of the head on the left 

1 Malgaigne, Ehrlich, Malgaigne, op. cit., torn. ii. p. 334. 



612 DISLOCATIONS OF. THE RIBS. 

shoulder, and rapid rotation backwards and to the right, together with 
direct pressure upon the left transverse process of the atlas. The condi- 
tion of the patient improved materially after extension had been made 
for some time with Glisson's apparatus. After the lapse of several 
weeks the patient was able to move his head in every direction. Barely 
a trace of the paralysis remained." 1 

§ 5. Dislocations of the Head upon the Atlas, or Occipito-Atloidean 

Dislocations. 

Lassus, Palletta, and Bouisson 2 have each reported one example of 
this dislocation. In neither case was the dislocation complete, but death 
occurred speedily in every instance. Dariste exhibited to the Anatomi- 
cal Society of Paris, in 1838, a specimen of incomplete luxation of the 
occipito-atloidean articulation, with stretching of the transverse liga- 
ment ; the patient from whom the specimen was taken having lived 
more than a year after the accident, when he died from a tubercle in 
the brain. 3 



CHAPTEK IY. 

DISLOCATIONS OF THE RIBS. 

The ribs may be separated from the bodies of the vertebrae, from the 
cartilages of the ribs, and from each other. The cartilages of the ribs 
may also be separated from the sternum. 

§ 1. Dislocations of the Ribs from the Vertebrae (Vertebro-costal). 

The heads of the ribs are joined to the bodies of the vertebrae by 
strong ligaments. The articulations are ginglymoid, admitting of motion 
chiefly in the direction of the axis of the spine. The mobility gradually 
increases as we proceed from the first rib downwards to the last. Each 
joint is furnished with a capsule. 

The necks and tubercles are also united to the transverse processes by 
ligaments, and the articulations are furnished with synovial capsules. 

I am not aware that any examples have ever been reported of disloca- 
tions of the ribs from the transverse processes. 

Examples of dislocation of the heads of the ribs have been mentioned 
by Ambrose Pare*, Bransby Cooper, Alcock, Donnie, Henkel, Kennedy, 
Buttet, and some others; but most of these reputed cases have 'not borne 
the test of a critical analysis, and while Vidal (de Cassis) is in doubt 

1 St. Louis Courier of Med., Jan. 1879, from Arch, fur Klin. Chirurgei. Cbl. f. Chir. 
Medicin. Chirurg. Rundshau, Sept. 1878. 

2 Lassus, Palletta, Bouisson, Malgaigne, op. cit. p. 320. 

8 Dariste, Amer. Journ. Med. Sci., Nov. 1838, p. 237, from Archives Gen., May, 
1838. 



DISLOCATIONS OF THE CARTILAGES OF THE RIBS. 613 

whether the claims of even one have been fully established, Boyer denies 
absolutely its possibility. We see no reason, however, to question the 
authenticity of several of these examples. 

The case mentioned by Bransby Cooper, although very briefly nar- 
rated, leaves no room for doubt as to its real character. " Mr. Web- 
ster, surgeon of St. Albans, when examining the body of a patient who 
had died of fever, found the head of the seventh rib thrown upon the 
front of the corresponding vertebra, and there anchylosed. Upon in- 
quiry, Mr. Webster learned that this gentleman, several years before, 
had been thrown from his horse across a gate, for which accident he 
had been subjected to the treatment usually followed in fractures of the 
ribs, and there is every reason to believe that it was at this time the 
dislocation occurred." 1 

These accidents seem to have been generally occasioned by a fall or 
a blow upon the back, and the dislocation has been accompanied, usually, 
with a fracture of some other rib, or of the transverse or spinous pro- 
cesses of the corresponding vertebrae. The head of the rib has always 
been found to be displaced inwards. The lower ribs, including the 
false and floating, are those which have been most frequently displaced. 

It would be difficult, if not impossible, during the life of the patient, 
to make a positive diagnosis, since the symptoms resemble so closely 
those which accompany a fracture of the rib near its posterior extremity. 
The nature of the accident producing the dislocation, the depression, 
mobility, and pain, are equally indicative of a fracture ; while the failure 
to detect crepitus might easily be explained by the thickness of the mus- 
cular walls at this point, or by the riding, or by other displacements of 
the broken fragments. 

Chelius speaks of a peculiar u rustling," perceived when the body 
and ribs are moved by the surgeon or by the patient himself, and which 
is different from the sensation produced by emphysema or fracture. 

The treatment ought to be the same which would be adopted in case 
the rib was broken. Replacement of the dislocated bone must be re- 
garded as impossible ; and it only remains that we insure quiet as far 
as possible in this portion of the chest, and combat the pain and inflam- 
mation by suitable remedies. The circular bandage, however recom- 
mended in these cases by Sir Astley Cooper, could only be serviceable 
in dislocations of those ribs which have an attachment to the sternum ; 
the floating ribs, which have been found dislocated quite as often as 
either of the others, could derive no support from circular pressure, or 
from any other mechanical contrivance. 

§ 2. Dislocations of the Cartilages of the Ribs from the Sternum 
(Sterno-Costal) . 

The cartilage of the first rib has no proper articulation at either ex- 
tremity, but the remaining six upper ribs, where they join the sternum, 
are furnished with synovial capsules. In old age these articulations gene- 
rally disappear, yet not always. 

1 Webster, B. Cooper's ed. of Sir Astley Cooper, Amer. ed., p. 450. 



614 DISLOCATIONS OF THE RIBS. 

Charles Bell observes: "A young man playing the dumb-bells, and 
throwing his arms behind him, feels something give way on the chest; and 
one of the cartilages of the ribs has started and stands prominent. To 
reduce it, we make. the patient draw a full inspiration, and with the fingers 
knead the projecting cartilage into its place. We apply a compress and 
bandage, but the luxation is with difficulty retained." 

Ravaton, Manzotti, and Monteggia have each, according to Malgaigne, 
reported one example of traumatic dislocation ; in all of which the carti- 
lages were thrown forwards in advance of the sternum. 

When treating of fracture of the sternum, I have related one case, 
which has come under my own observation, of dislocation of three or 
four cartilages at the same time. 

Dr. Samuel D. Flagg, of St. Paul, Minn., relates as follows: — 

"During the evening of June 29th, 1871, a girl, set. 10, while playing 
with several children, ran violently against the corner of an ordinary deal 
table. It is stated that the child was faint and breathed with difficulty 
for a short time, but soon returned to play. No swelling or other evi- 
dence of injury was observed by her friends. 

" On the 1st of July, about forty-eight hours after receiving the injury, 
while exercising somewhat violently, she complained of sudden pain at 
the left costo-sternal articulation and a sensation of something having 
given way. Soon afterwards I saw the child for the first time, and found 
a slight non-crepitant swelling at the latter point, and the sternal extremity 
of the cartilage of the fourth rib displaced forward, its posterior surface 
being very nearly on a plane with the anterior surface of the sternum. 
A minute fragment of bone, unconnected with the sternum or cartilage, 
was noticed, which I took to be a fragment chipped off from the margin 
of the articular depression on the edge of the sternum. Neither pain 
nor embarrassed respiration were notably prominent ; crepitus could be de- 
tected, but not very distinctly ; preternatural mobility was very evident." 1 

By pressure alone restoration has generally been effected, the cartilage 
resuming its position suddenly and with a sound. The reduction may. 
nevertheless, be facilitated by bending the trunk backwards, or by direct- 
ing the patient to make a full inspiration. 

To maintain the reduction has been found more difficult, and Sir Astley 
directs " a long piece of wetted pasteboard should be placed in the course of 
three of the ribs and their cartilages, the injured rib being in the centre; 
this dries upon the chest, takes the exact form of the parts, prevents 
motion, and affords the same support as a splint upon a fractured limb. 
A flannel roller is to be applied over this splint, and a system of deple- 
tion pursued, to prevent inflammation of the thoracic viscera." Instead 
of the pasteboard, we might use either felt, sole-leather, or gutta-percha. 

The patients spoken of by Ravaton and Manzotti were both cured in 
about one month. 

Mr. Bransby Cooper says that a baker's boy applied for relief at Guy's 
Hospital, who was the subject of displacement of the cartilages of the 
fifth and sixth ribs from their junction with the sternum, produced partly 
by the constant action of the pectoral muscles in kneading bread, but 

1 Flagg, Northwestern Med. and Surg. Journ., Aug. 1871. 



DISLOCATIONS OF THE CLAVICLE. 615 

principally by his defective constitution. Mr. Cooper stated to the boy 
the necessity of changing his occupation, and advised him to go into the 
country; but as he was unable to do so, little hope was entertained of 
his recovery. 1 

I 3. Dislocation of one Cartilage upon Another. 

The cartilages on the sixth, seventh, and eighth ribs are furnished at 
their lower borders with a true arthrodial joint, by which they articulate 
with the corresponding cartilages. This arrangement sometimes extends 
to the fifth and ninth ribs. 

A displacement of these articulations may take place when one falls 
upon his back, striking upon some projecting body, so that the chest is 
suddenly thrown forwards; in consequence of which the upper margin 
of the lower cartilage is depressed and entangled behind the lower margin 
of the upper. The inferior cartilage is, therefore, the one which is dis- 
placed rather than the superior, although this latter, being made promi- 
nent by the pressure of the other from behind, seems alone to be dis- 
placed. Boyer, Martin, and Malgaigne have each reported one example. 

It is probable that the contraction of the pectoral and abdominal 
muscles has a chief agency in the production of these dislocations, and 
that they are not solely or directly due to the shock of the accident. 

The treatment consists in pressing firmly upwards and backwards 
against the inferior margin of the upper, or overlapping rib, so as to dis- 
engage it from the lower, when by its own elasticity it will resume its 
natural position. The redaction might also be aided by a full inspiration. 



CHAPTER V. 

DISLOCATIONS OF THE CLAVICLE. 

Of 57 dislocations of the clavicle observed and recorded by me, 13 
belonged to the sternal end and 44 to the acromial. Of those belonging 
to the sternal end, 11 were dislocations forwards, forwards and upwards, 
or forwards and downwards, and 2 were upwards. I have never met 
with a dislocation backwards. Of the acromial dislocations the whole 
number were dislocations upwards, or upwards and outwards. 

§ 1. Sterno-Clavicular. 
(a) Dislocation Forwards at the Sternal End. 

Causes. — This accident is generally caused by a fall upon the point — 
outer surface — of the shoulder, in consequence of which the sternal end of 
the clavicle is driven forcibly inwards and forwards. It is probable, also, 
that the blow which produces the dislocation is received rather upon the 

1 B. Cooper's ed. of Sir Astley Cooper, etc., op. cit., p. 447. 



616 DISLOCATIONS OF THE CLAVICLE. 

anterior and outer than exactly upon the outer face of the shoulder. A 
sudden effort of the muscles, as in the attempt to balance a weight upon 
the head, or to throw the shoulders backwards when under drill, has 
been known also to produce this dislocation. In one example it was 
occasioned by placing the knee against the spine and drawing the 
shoulders forcibly back. Various other accidents, the philosophy of 
whose agency is not so easily explained, are said to have produced the 
same result ; but it is not improbable that in many of these cases the 
precise manner in which the injury was received has not been correctly 
understood or reported. 

Mr. Fergusson has once seen this displacement in a newly-born infant, 
which had happened during birth. It could be replaced with ease, but 
immediately slipped out again when left to itself. " Nothing was done ; 
a new joint formed, and the child afterwards possessed as much power 
in the one arm as in the other;" 1 and Dr. W. C. Shaw, of Pittsburgh, 
Pa., has also seen a congenital case. 2 

The following is an example of double forward luxation at the sternal 
end: Agnes Moriarty, get. 17, in a collision on the Third Avenue Elevated 
Railroad, March 25, 1879, was thrown violently, it is supposed, against 
the door, striking her left shoulder, and then by a rebound striking the 
floor of the car with the right shoulder. By courtesy of Drs. McGruire 
and King, her attending surgeons, I saw her on the fourth day after the 
accident. Exposing her shoulders, we observed an extensive ecchymosis 
on the outer surface of the right shoulder, extending some distance down 
the arm. While seated in a chair both clavicles were subluxated forwards 
and a little upwards, the right ascending a little higher than the left. 
She could not raise her arms to her head ; but when lifted to this posi- 
tion the dislocations became complete, and when let fall the bones would 
resume their positions of subluxation with a click. The bones could not 
be pushed completely into their sockets, and pulling the shoulders back 
increased the displacement ; but when lying flat on her back they went 
nearly into place. At my suggestion she was kept in this position six 
weeks, but with no result ; the bones still becoming displaced whenever 
she got up. Some months after the accident she was still suffering from 
the general disturbance to her spine and nervous system caused by the 
shock, and the arms had not recovered their original strength. 

Symptoms. — The head of the bone, unless the person is exceedingly 
fat, or great swelling has supervened, can be distinctly felt and seen in 
front of the sternum; the corresponding shoulder falls a little back; the 
head inclines also sometimes to the same side ; the movements of the arm 
are embarrassed, and accompanied almost always with an acute pain at 
the point of dislocation. The clavicular portion of the sterno-cleido- 
mastoid muscle presents an unusually sharp and projecting outline, and 
a careful measurement indicates, if the dislocation is complete, a sensible 
approach of the acromion process toward the centre of the sternum. If 
now the surgeon places his knee against the spine, and draws the shoul- 
ders back, the projection of the clavicle in front usually diminishes or 

1 Fergusson, System of Practical Surgery, Amer. ed., 1853, p. 203. 

2 Shaw, Med. Record, Aug. 18, 1877. 



DISLOCATION FORWARDS AT THE STERNAL END. 617 




Dislocation of the sternal end forwards . 



disappears ; if he carries the shoulder Fig. 255. 

up, it descends ; and if he depresses 
the shoulder, it ascends. 

The simplicity and uniformity of the 
symptoms which usually characterize 
this accident will generally prevent the 
possibility of a mistake ; but Pinel 
mentions the case of a man who, hav- 
ing presented himself at one of the hos- 
pitals of Paris, suffering under this 
dislocation, the surgeon-in-chief thought 
it a tumor of the bone, and advised the 
application of a plaster ; and, on the 
other hand, a patient presented himself 
to Velpeau, who had been treated for 

a dislocation, when the bone was only expanded by disease. I have 
myself also seen a fracture so near the sternal end of the bone as not 
to be easily distinguished from a dislocation. 

Pathology. — In complete anterior luxation of the clavicle, the cap- 
sular ligament suffers a complete disruption, and also the anterior with 
the posterior sterno-clavicular ligaments. The rhomboid and interarticu- 
lar ligaments suffer more or less, according to the extent of the displace- 
ment. The interarticular cartilage may retain its attachment to the 
sternum, or it may be carried forwards with the clavicle. The head of 
the bone lies immediately underneath the skin and in front of the ster- 
num ; and generally it is found to have descended a little upon its ante- 
rior surface. Richerand saw a case in which the sternal extremity of 
the bone was placed three inches below the top of the sternum. In some 
cases it is situated in front and a little above the sternum. 

Wherever the bone lies it carries with it the clavicular fasciculus of 
the sternocleidomastoid muscle. 

Treatment. — Not one of the 11 forward dislocations of the clavicle at 
the sternal end seen by me has been completely reduced, or if reduced 
they have not been retained in place. In the following example the 
reduction, although faithfully attempted, was never accomplished. 

Mr. H., of Buffalo, set. 15, was thrown by a horse, suffering at the 
same moment a fracture of the leg and a forward dislocation of the left 
clavicle at its sternal end. 

Prof. James P. White, with whom I was in consultation, made several 
attempts to reduce the dislocation by placing the knee against the spine 
and pulling the shoulder forcibly back, and the same efforts were re- 
peated by myself, but without accomplishing the reduction. We also 
endeavored to reduce it by pressing directly upon the projecting bone 
and by placing a pad in the axilla, using the arm as a lever, as recom- 
mended by Desault, and with no better result. 

The patient was tolerably muscular, but while we were manipulating 
he was very much enfeebled by the shock of the accident. 

Finding that it was impossible to reduce the dislocation by any mode- 
rate amount of force, and believing that if we were to succeed we could 
not retain the bone in place, and the more especially because his left 
40 



618 DISLOCATIONS OF THE CLAVICLE. 

side was so much bruised that he could not bear an axillary pad or ban- 
dages of any kind, we desisted from any further attempts. 

Two years later I examined the shoulder and found the clavicle still 
unreduced, and its- position unchanged. When he carries the shoulder 
forwards or backwards, there is a corresponding motion at the sternal 
end of the clavicle. The arm is not quite as strong as the other, and its 
freedom of motion is slightly impaired. 

I have also in my museum the cast of a case of complete forward dis- 
location at this point ; which accident occurred in a lad twelve years old, 
who had fallen into a cellar on the 20th of August, 1856. The late 
Dr. Lewis and Dr. Dayton, both excellent surgeons, had examined the 
arm, and dressings had been applied with a view to maintain the reduc- 
tion ; but on the fifth day after the accident I found the bone displaced ; 
nor do I think reduction was ever afterwards maintained. 

A lad was brought into the Buffalo Hospital of the Sisters of Charity, 
with a dislocation of the same character, on the 25th of Sept. 1858, 
who had been run over by a wagon on the same day. Dr. E. P. Smith, 
one of the surgeons of the hospital, attempted faithfully to reduce it, 
but was unable to do so. Five days after, I found the bone out and 
quite movable. All apparatus having been removed, Ave laid him upon 
his back in bed, and kept him in this position three weeks. He was 
then dismissed with no change in the appearance of the bone, but he 
could move the arm as well as before the accident. 

Other surgeons have not met with, or at least they have not men- 
tioned, any cases in which the reduction of this dislocation was attended 
with difficulty, nor am I prepared to explain the difficulty which was 
experienced in my own (Mr. H.), and in Dr. E. P. Smith's case. Prob- 
ably they ought to be regarded as exceptions to the general rule. But 
most surgeons have testified to the difficulty of retaining it in place when 
reduction has been fairly accomplished. Chelius says, "there commonly 
remains more or less deformity," and Malgaigne says that " it is difficult 
and rare to cure it without deformity." 

Nevertheless, Desault (or, rather, his pupil Bichat, who has published 
his lectures), who always speaks very confidently of his ability to re- 
tain either broken or dislocated bones in their places, says that he 
" almost always obtained complete success" with his apparatus. It is 
remarkable, however, that of the three examples furnished by Bichat to 
confirm this statement, all of which were treated by Desault himself, one 
recovered after a long time with a "very perceptible protuberance in 
front of the sternum," one with a "very slight protuberance," and in 
the other the " swelling was almost gone" on the twentieth day, and we 
are left in doubt as to whether the reduction was any more complete 
than in either of the other cases. 1 Richerand and Guersant succeeded 
no better with Desault' s dressings. 2 

Other surgeons have made similar claims for their own forms of appa- 
ratus, but experience still continues to show that a complete retention of 
the dislocated bone is seldom to be expected. 

Sir Astley Cooper recommends an apparatus, the construction and 

1 Desault on Fractures and Dislocations, by Xav. Bichat, Philada. ed., 1805, p. 52. 

2 Malgaigne, op. cit., torn. ii. p. 417. 



DISLOCATION FORWARDS AT THE STERNAL END 



619 




Sir Astley Cooper's apparatus for dislocated clavicle. 



application of which are illustrated by the accompanying sketch, the 

object of which is to draw the 

shoulders back, and at the same 

time, by the aid of two pads or 

cushions in the axillae, to carry 

the shoulders outwards. The 

dressing is then completed by 

placing the arm in a sling. He 

advises, however, that in some 

way direct pressure should be 

made upon the projecting point 

of bone. 

Velpeau objects to any plan 
which will draw the shoulders 
back ; but, on the contrary, he 
thinks that the shoulders should 
be kept slightly forwards, so as 
to diminish the tendency of the 
sternal end of the clavicle to 
escape in this direction. 

Until further observations have 
determined the relative value of 
these and of many other pro- 
cesses, it will be well to adopt no 
fixed rule of action ; but, having 
reduced the bone by either placing the knee upon the spine and drawing 
the shoulders back, or by making use of the humerus as a lever, we 
recommend that the surgeon shall seek to maintain it in place by such 
means as the experiment shall prove are most successful. Among these 
means, direct pressure upon the sternal end of the clavicle, the sling, 
and perfect quietude of the muscles of the arm through the aid of band- 
ages, w T ith dorsal decubitus, are no doubt of the greatest importance. If 
we find that a position of the shoulders more or less forwards or back- 
wards best maintains the apposition, this position, whatever it is, ought 
to be continued. 

Dr. Gross says he first suggested using strong silver wire to keep the 
parts in place, and this suggestion has been carried into effect first by the 
late Dr. Cooper, of San Francisco, and then by Dr. Hodgen, of St. 
Louis. 1 I do not think the practice can be commended. 

In order to be successful, sufficient time must elapse for the torn liga- 
ments to become firmly reunited, during which the reduction must be 
constant ; since every time the bone escapes, the whole work of repair 
has to be recommenced as from the beginning". To this end at least four 
or six weeks are necessary, and sometimes the period must be lengthened 
far beyond these limits ; so that it may often become a grave point of 
inquiry whether the long confinement of the limb will not entail more 
serious consequences than have ever been known to arise from leaving 
the bone displaced. In no case seen by me has the function of the arm 
been very seriously impaired by the displacement. 



1 Amer. Journ. Med. Sci., April, 1876, p. 452; Ibid., April, 1861, p. 389. 



620 DISLOCATIONS OF THE CLAVICLE. 

(b) Dislocation of the Sternal End of the Clavicle Upwards. 

Malgaigne has collected four undoubted examples of this dislocation. 
Mr. Bryant mentions two cases seen by himself, one of which was a 
double dislocation. He refers also to a specimen in Guy's Museum, 
dislocated upwards and forwards. 1 Dr. Shaw, of Pittsburgh, Pa., has 
reported one case in an adult caused by a fall. 2 Vanvert has reported 
a case, in the Gazette des Hopitaux, caused by a blow upon the side of 
the chest, which he was unable to reduce. 3 I have been unable to find 
a report of any other except the very extraordinary case described by 
Dr. Rochester, at the September meeting of the Buffalo Medical Asso- 
ciation, and which case, through the courtesy of Dr. Rochester, I was 
permitted to see several times. 4 

Jerry McAuliffe, set. 44, on the 28th of August, 1858, while seated 
upon a load of wood, was caught under the bar of a gateway and 
violently crushed, the right shoulder being forced downwards and a 
little backwards. Dr. Rochester saw him very soon after the accident. 
On examination, it was found that the sternal extremity of the right 
clavicle was thrown upwards so far as to rest upon the front of the 
thyroid cartilage, occasioning considerable pain, difficulty of respira- 
tion, and loss of speech. Reduction was easily effected, and a retentive 
apparatus was immediately applied, consisting of a gutta-percha splint, 
moulded to the clavicle and ribs, and retained in place with adhesive 
plaster. Suitable bandages, a sling, etc., were also employed to main- 
tain complete rest. 

Notwithstanding all the care employed, the bone again became dis- 
placed, and Avhen, near four months after the accident, this man came 
before the class of medical students at the Hospital of the Sisters of 
Charity, we found the sternal end of the clavicle carried upwards half 
an inch, and across toward the opposite side also about half an inch, 
and projecting somewhat in front. It was fixed in this position by 
ligaments which allowed it to move much more freely than natural, 
but which would not permit any great displacement. The correspond- 
ing shoulder was slightly depressed. McAuliffe said that he felt no 
inconvenience or abatement of strength in the arm except when he 
attempted to lift weights above his head. 

In April, 1870, I met with a similar case in a woman fifty years of 
age, which had been caused by a fall upon the shoulders nine weeks 
before, and which had been overlooked by her surgeon in the first in- 
stance. When seen by me it was immovably fixed in its new position. 

The accident seems to have been produced, in all the cases, so far 
as can be ascertained, by a force operating upon the end and top of 
the shoulder ; in consequence of which the head of the clavicle is 
pushed and at the same time lifted, as it were, from its socket, tearing 
not only its capsule with the ligaments which immediately invest the 
capsule, but also in some instances the costoclavicular ligament with 

1 Bryant, Practice of Surgery, p. 787, London, 1872. 

2 Shaw, Med. Record, Aug. 18, 1877. 

3 Vanvert, New York Med. Journ., March, 1879, p. 329. 

4 Rochester, Buffalo Med. Journ., vol. xiv. p. 262. 



OF THE STERNAL END OF CLAVICLE BACKWARDS. 621 

some fibres of the subclavian muscle. The sternal end of the clavicle 
is found riding upon the top of the sternum, its head being placed 
between the sternal fasciculus of the sterno-cleido-mastoid muscle on 
the one hand, and the sterno-hyoid muscle on the other. In one of the 
cases seen by Malgaigne, the head had traversed in this direction com- 
pletely the intra-clavicular space, and lay behind the sternal portion of 
the opposite sterno-cleido-mastoid muscle. 

Symptoms. — The symptoms are, a depression of the shoulder, with an 
elevation of the sternal end of the clavicle so as to increase sensibly the 
space between it and the first rib. The clavicle also encroaches more or 
less upon the supra-sternal fossa, occasioning a corresponding diminu- 
tion of the space between the end of the shoulder and the centre of the 
sternum. The sternal portion of one or both of the sterno-cleido-mastoid 
muscles may also be seen raised and rendered tense by the pressure of 
the head of the bone from behind. 

Fig. 257. 




Dislocation of the sternal end of the clavicle upwards. 

Treatment. — Reduction has been found easy, but Malgaigne thinks a 
perfect retention impossible, at least it does not seem to have been 
accomplished in any of the cases reported. In no case did the displace- 
ment seriously impair the functions of the arm. 

The same apparatus to which we shall give the preference in cases 
of dislocation upwards of the acromial end of the clavicle, at least with 
only such slight modifications as the peculiarities of the case will natu- 
rally suggest, will be suitable for this accident. The shoulder must 
be lifted by a sling, while the sternal end of the clavicle is pressed 
downwards by a pad and bandages ; and all the muscles of the arm 
and chest, so far as is consistent with respiration and comfort, must be 
maintained in a state of perfect rest until the ligaments have become 
reunited. 

(c) Dislocations of the Sternal End of the Clavicle Backwards. 

The first case upon record of this kind of accident, caused by violence, 
was published by Pellieux, in 1831, in the Revue MeMcale; until which 



622 DISLOCATIONS OF THE CLAVICLE. 

time its existence had been generally denied. In the London and 
Edinburgh Journal of Medical Science for October, 1841, several cases 
are mentioned. 

Two forms of the accident have been described, one in which the head 
of the clavicle is driven backwards and a little downwards ; and another 
in which it is displaced directly backwards, or backwards and a little up- 
wards. In both of these classes, the end of the bone falls inwards toward 
the opposite clavicle, and occupies a space in the cellular tissue back of 
the sterno-hyoid and sterno- thyroid muscles, and in front of the oesopha- 
gus ; the trachea, if reached at all, being probably thrust to the opposite 
side. 

The examples in which it has been found beloAV the top of the sternum 
are much the most numerous ; indeed, it is probable that the other form 
is only a secondary displacement, occasioned by the action of the fibres 
of the sterno-cleido-mastoid muscle. 

Causes. — Of the eleven examples mentioned by Malgaigne, four were 
occasioned by direct blows, and most of the remainder by crushing acci- 
dents, as by powerful lateral compression of the shoulders. 

One of the cases produced by a direct blow was accompanied with an 
external wound, and is the only instance of a compound dislocation of 
this kind which I have found upon record. The man was admitted into 
St. Thomas's Hospital in Sept. 1835, and, according to his own account, 
the sharp end of a pickaxe had been driven through the flesh against the 
bone. The sternal end of the clavicle was found to be displaced back- 
wards, and with the finger thrust into the wound on the front of the chest, 
it could be distinctly felt resting upon the side and front of the trachea, 
where it interfered somewhat with respiration and deglutition. He had 
a great desire to cough, with a sensation of pressure on his windpipe, 
which was greatly increased when his head was thrown back. There 
was also a slight emphysema in the region below the collar-bone and over 
the top of the sternum. The shoulder having been brought back with 
straps attached to a back-board, the bone readily resumed its place. The 
elbow was then brought forwards and bound to the side, and the wound 
being closed with adhesive plaster, he was put to bed with the shoulders 
much raised. No unfavorable symptoms followed, and in three weeks 
he left his bed. Three weeks later he left the hospital with the sternal 
end of the bone still falling a little backwards, and rather more movable 
than natural. 1 

The following example, related by Morel-Lavallee, will illustrate that 
class in which the dislocation results from an indirect blow, or from a 
crushing accident. 

Lemoine, seventeen years old, had his right shoulder violently pressed 
against a wall by a carriage. He experienced at the moment some pain 
at the bottom of his neck, and a great sensation of suffocation, which 
lasted for more than a quarter of an hour. The dyspnoea gradually sub- 
sided, but the motion of the right arm not returning, he, on the eighth 
day after the accident, entered La Charity. On examination, the two 
shoulders were found to be on the same level, but the right one was nearer 

1 South, note to Chelius's Surgery, Amer. ed., vol. ii. p. 218. 



OF THE ACROMIAL END OF CLAVICLE UPWARDS. 623 

the median line. The internal extremity of the clavicle was half con- 
cealed behind the sternum. On depressing the shoulder, the inner end 
of the clavicle arose and disengaged itself from behind the sternum ; but 
reduction was effected by elevating the shoulder, while at the same time 
it was carried outwards and backwards. Desault's bandage was then 
applied, but as it became loosened, Velpeau's was substituted, which kept 
the bone completely in position until the eighteenth clay, when the patient 
was lost sight of. 1 

Symptoms. — The most constant symptoms are, the absence of the head 
of the bone from its socket, and its complete or partial disappearance 
behind the sternum, an approach of the corresponding shoulder to the 
median line, an inclination of the head to the opposite side, elevation of 
the shoulder, pain at the bottom of the neck, impairment of the motions 
of the arm, sometimes difficulty in respiration and in deglutition, partial 
arrest in the circulation of the arm from pressure upon the subclavian 
artery, and a slight projection of the acromial end of the clavicle) noticed 
twice by Morel-Lavallee. 

Treatment. — It has not generally been found difficult to reduce this 
dislocation, nor, when reduced, is it so liable to again become displaced 
as are the dislocations forwards ; yet in only a few instances has. the re- 
storation been so complete as not to leave some deformity. 

In order to the reduction, the shoulder must be carried generally up- 
wards, outwards, and backwards ; and it may then be best maintained in 
position by laying the patient on his back upon an elevated cushion, as 
practised by Tyrrell in the case related by South. To this may be added 
such other measures, differing but little from those employed in other 
dislocations of the clavicle, as are necessary to insure complete rest to 
the muscles. Of course, no pads or bands across the clavicle can be of 
any service in this case. 

As in the other cases of dislocation at this point, the patients have 
generally recovered nearly the full use of their arms, even in one or two 
instances in which the reduction has never been accomplished. 

§ 2. Acromioclavicular. 

(a) Dislocation of the Acromial End of the Clavicle Upwards. 

Of all the dislocations of the clavicle, this form is most frequent. I 
have met with it either as a partial or complete traumatic luxation forty- 
three times. The youngest subject was seven years of age, and the 
oldest sixty-three. All but two were males. 

I have seen one example of congenital complete upward and outward 
dislocation of the acromial end, which was not traumatic — the case of 
Mary Ann Hughes, who was examined by me Feb. 8, 1876, when she 
was four weeks old. The labor had been easy and natural, and there 
was no soreness over the joint. It was easily reduced, but could not 
be maintained in place. 

Causes. — It is produced generally by a fall upon the extremity of the 
shoulder. Twice the blow has been received rather upon the back than 

1 Morel-Lavallee, Amer. Journ. Med. Sci., vol. xxix. p. 229, 1842; from daz. Med. 



624 DISLOCATIONS OF THE CLAVICLE. 

upon the extremity, and once it was occasioned by the fall of a board 
directly upon the top of the shoulder, and once by a bolt thrust directly 
up from under the clavicle. 

Symptoms. — When the dislocation is complete, the clavicle not only is 
lifted from its articular facet to the extent of the breadth of the bone, 
but it is pushed more or less outwards over the top of the acromion pro- 
cess ; generally less than half an inch, but I have once seen it riding the 
process to the extent of three-quarters of an inch. In this last example, 
the case of James Moran, a strong, healthy laboring man, the clavicle 
was easily reduced, and it always went into place with a sensible click ; 
but although every possible care was taken to retain it in place by band- 
ages, compresses, an axillary pad, and a sling, yet it was not accom- 
plished, and on the third day he removed all the dressings, and refused to 
have them reapplied. 

I have usually found the shoulder slightly depressed ; and in one in- 
stance, where it is probable the deltoid muscle had suffered some injury, 
the elbow hung away from the body, and any attempts to lay it against 
the side produced an acute pain in the shoulder. 1 It has been noticed 
also, in most cases, that the clavicular portion of the trapezius muscle 
appeared lifted and tense, especially when the neck was straight. 

Inability to raise the arm to a right angle with the body is a general 
but not constant symptom. In two instances, where the displacement 
was only moderate, the patients were at first and for some time after- 
wards unable to lift the arm in any degree from the side. In one ex- 
ample, a lady sixty years of age had fallen upon her shoulder and pro- 
duced a dislocation upwards, but she had not consulted a surgeon until 
she called upon me, five months after the accident. The clavicle was 
then raised from its socket about half an inch, but it could be easily 
pressed back to its place, the reduction being attended with a grating 
sensation, a circumstance which I have not noticed in any other instance. 
She was not even then able to raise her arm to her head, nor had she 
been able to do so since the accident occurred. 

In all the motions of the arm and shoulder, the clavicle is seen to 
move more freely than natural inrniecliately under the skin, and these 
motions are usually attended with some pain at the point of dislocation. 

This accident has been sometimes mistaken for a dislocation of the 
humerus, but, unless the shoulder is already greatly swollen, the error 
is not likely to happen. If the point of the acromion process can be 
made out, it will be easy to determine, by sliding the' finger along its 
spine, whether the clavicle is displaced or not, and by these means to 
settle the question of its complicity in the accident. The question as to 
whether the shoulder is dislocated or not may be more difficult of solu- 
tion, as we shall hereafter have occasion again to observe. 

Pathology. — Generally there exists simply a rupture of the ligaments 
immediately investing the joint, so that the clavicle rises from its socket 
only about half an inch, more or less, according to its diameter, and is 
carried outwards just sufficiently far to allow it to rest upon the -upper 

1 Report on Dislocations, by the author. Transac. of New York State Med. Soc, 
1855, p. 19. 



OF THE ACROMIAL END OF CLAVICLE UPWARDS. 625 

margin of the acromial articulation. In at least thirty of the cases seen 
by me this has been the position of the acromial end of the clavicle, and 
for its complete reduction nothing more has been required than to press 
with moderate force upon the upper and outer end of the bone. 

In nine cases I have found the bone not only thus lifted in its 
socket, but also driven over upon the acromion process from half to 
three-quarters of an inch ; and in one instance, that of a gentleman, 
Mr. B., who was injured in a railroad accident, the acromial end of the 
clavicle was displaced outwards half an inch and backwards three- 
quarters of an inch, while the sternal end also was considerably lifted 
in its socket and slightly sent inwards. The shoulder fell forwards 
and the coracoid process was one inch nearer the sternum than the 
same process upon the opposite side. In such cases more or less of the 
fibres of the coraco clavicular ligament must have suffered a disrup- 
tion ; indeed, without a rupture of its external fasciculus, which anato- 
mists have called the trapezoid ligament, such a dislocation cannot take 
place . 

Prognosis. — It is impossible for me to say what has been the precise 
result in all the cases which I have seen, but my notes furnish only two 
cases of perfect retention after a complete dislocation at this point. 



Fig. 258. 



Fig. 259. 





Dislocation of the acromial end of the clavicle 
upwards. 



Dislocation of the acromial end of the 
clavicle upwards and outwards. 



One of these, David Thomas, aged about twenty-five years, fell side- 
ways upon the ground, striking upon the extremity, and, as he thinks, 
a little upon the top of the shoulder. The clavicle was dislocated up- 
wards and outwards, so that it overlapped the acromion process half an 
inch. It was easily replaced, and having applied my own apparatus for 
broken collar-bones, with the addition of a band across the shoulder and 
under the elbow to keep the clavicle down, I succeeded in retaining the 
bone in place. This dressing was continued until the forty-second day, 
when, on being removed, the clavicle was seen to be closely confined 
upon its articulation; and after a lapse of two years it still retains its 



626 DISLOCATIONS OF THE CLAVICLE. 

position so completely that no difference can be detected between the 
opposite articulations. 

In the case of Moran, already mentioned, whose clavicle overlapped 
the acromion process three-quarters of an inch, and who threw off the 
dressings at the end of three days, the same degree of displacement ex- 
isted at the end of two years ; the scapular end of the clavicle moving 
freely in every direction under the skin according as the arm was moved. 
In lifting, he says, the strength of his arm is undiminished until he 
raises the weight nearly to a level with his shoulders, and from this 
point upwards he can lift but little. For a laboring man it amounts to 
a serious maiming. I have seen the same loss of power in the arm to 
raise bodies above the head in at least two or three of the examples of 
less complete luxation, continuing after the lapse of several years ; but 
in the majority of cases, although the bone does not remain reduced, 
the patients have recovered eventually the complete use of the arm in 
whatever position it may be placed. 

The case to which I have already referred as having been caused by 
a bolt thrust upwards under the clavicle, will furnish the best illustra- 
tion of this general principle. James O'Brien, 1st U. S. Artillery, was 
injured in September, 1862, by being run over by a horse-car. A bolt, 
three quarters of an inch in diameter, was driven through the skin on 
the anterior margin of the left axilla, breaking the first rib, severing the 
coraco-clavicular ligaments, and forcing the clavicle upwards from its 
socket. No attempt at reduction was ever made. When seen by me 
one year after the accident, the outer end of the clavicle was lifted 
directly up two inches from the acromion process, to which it was united 
only by a long and slender ligament. He was not conscious of any loss 
of power or limitation of motion in the injured arm. At my request, 
my son, then in the U. S. service, instituted a series of experiments to 
test the relative strength of the two arms, and with the following result : 
First with the right arm, and then with the left, he lifted from the 
ground fifty-six pounds and three ounces, and sustained this weight above 
his head thirty seconds, with his arms fully extended. With his right 
arm extended at full length, at right angles with his body, he sustained 
twenty-five pounds for fifteen seconds. With the left arm he sustained 
the same weight, in the same position, seventeen seconds. 1 

Treatment. — When the bone simply rises upon its socket, the reduc- 
tion is always easily accomplished by pressing firmly upon its extremity 
with the fingers ; but if, at the samo tim-j, it has been carried outwards, 
or outwards and backwards, the reduction is only accomplished by 
pulling the shoulders backwards, or by placing a pad in the axilla, 
using the arm as a lever, or by lifting the arm by the elbow and at the 
same time pressing the clavicle down ; and it will sometimes require the 
application of all or several of these procedures at the same moment. 
In some cases the complete reduction has only been effected when the 
patient has been brought under the influence of an anaesthetic. 

As to the maintenance of the bone in its socket for a length of time 
sufficient to insure a firm and close union of the torn ligaments and cap- 

1 Am. Med. Times, Oct. 24, 1863. 



OF THE ACROMIAL END OF CLAVICLE UPWARDS. 627 

sule, this will be found always more difficult, and, in a great majority of 
cases, absolutely impossible. Nearly all surgeons who have written 
upon this subject have made the same observation; and if occasionally a 
new apparatus in the hands of a clever surgeon has seemed to promise 
better results, the same apparatus in the hands of other equally clever 
surgeons, and under circumstances equally favorable, has been found 
almost constantly to fail; and we have been compelled again to exercise 
anew our ingenuity, and to seek for new resources, or to abandon the 
effort in despair. 

Dr. Folts, of Boston, believed that he had found in Bartlett's appa- 
ratus for broken clavicles, modified by the application of a shoulder- 
strap, the infallible remedy for this one of the many sad defects in our 
art. The most important part of this dressing, according to Dr. Folts, 
is the compress placed upon the upper and outer end of the clavicle, and 
the bandage or strap passed over the compress and under the point of 
the elbow. 1 

Dr. Folts is no doubt correct in regarding this strap as an important 
if not the essential part of the apparatus ; and it is surprising that by 
Sir Astley Cooper, as well as by many other experienced surgeons, its 
value should have been overlooked. The chief obstacle to the retention 
of the bone in place is the powerful action of the trapezius, which con- 
stantly tends to elevate the outer end of the bone. In some measure 
this may be overcome by elevating very forcibly the shoulder, or by in- 
clining the head, but both of these positions are extremely fatiguing, 
and will not be long endured. The bandage or strap, adjusted in the 
manner which Dr. Folts has recommended, is the only means of counter- 
acting the action of the trapezius, upon which any substantial reliance 
can be placed ; but the principle has long been understood and practised 
upon. Brasdor's tourniquet, or Petit's, secured by a strap brought 
under the point of the elbow, Boyer's double shoulder-straps, and De- 
sault's third bandage, all aimed at the accomplishment of the same pur- 
pose ; yet Boyer and Desault found all these contrivances fail in a 
majority of cases. Mayor employed a dressing constructed with a strap 
to buckle over the dislocated clavicle ; but Xelaton has seen this apparatus 
fail also, when applied in his own wards. 

The experience of Dr. Folts at the time of his report did not extend 
beyond three cases, and the apparatus had been completely successful in 
only two of the three. Our own experience is sufficient to show that it 
will be found occasionally, but by no means constantly, successful. We 
have already mentioned two cases in which we succeeded perfectly by 
this mode, but in several others which seemed equally favorable we have 
met with partial or complete failures. 

The source of error, generally, on the part of those who think that 
they have devised an apparatus, or a method by which they can always 
or generally succeed in holding the bone in place until the ligaments are 
reconstructed, is, first, that they have not sufficiently noted how slight 
is the elevation, or projection, in a large majority of cases, before any 
dressing is applied, so that finding eventually very little projection, they 

1 Folts, Bost. Med. and Surg. Journ., vol. liii. p. 259. 



628 



DISLOCATIONS OF THE CLAVICLE. 



Fig. 260. 



call it perfect; second, that they examine the shoulder, to determine 
whether the restoration is complete, too soon after the apparel is re- 
moved, when a very slight remaining eifusion into, and induration of the 
adjacent tissues, render it impossible to say what has been accomplished; 
and, third, they have sometimes had under treatment too small a number 
of cases to entitle them to form a just conclusion as to the general value 
of their method of treatment. 

The practical difficulties are, the sensibility and consequent inability 
sometimes of the point of the elbow to bear the requisite pressure, and 

the even greater sensibility of the 
skin over the top of the clavicle ; 
the tendency of the bandage to 
slide off from the shoulder, and 
also to become displaced from the 
end of the elbow; the gradual re- 
laxation of the bandages, which, 
when existing even in the most 
inconsiderable degree, is sufficient 
sometimes to allow the bone to 
slip out from its shallow socket ; 
the impossibility of fixing the 
scapula, upon whose immobility as 
well as upon the immobility of the 
clavicle the retention depends; 
and, finally, the great length of 
time requisite to unite firmly the 
ligaments, if indeed they ever 
again become actually united. 

The band can be prevented in 
some measure from sliding off 
from the clavicle by a counter- 
band attached to a collar upon 
the opposite shoulder, but not without causing some pain, and giving rise 
to excoriations generally in the opposite axilla ; and, in a degree, all the 
other difficulties may be met by patience and ingenuity, but unfortu- 
nately the smallest failure in any one of these numerous indications in- 
sures a defeat. 

The axillary pad employed as a fulcrum upon which extension may 
be made is equally as dangerous here as in fractures, and I do not think 
it ought ever to be used for this purpose, but only as a means of mode- 
rate support and retention; indeed it would be well, perhaps, if it were 
discarded altogether. 

The case of Mr. B., already quoted, with a dislocation outwards and 
backwards, affords not only an illustration of the inefficiency of either 
the shoulder-strap or the axillary pad in certain cases, but also, it seems 
to me, of the mischief which may result from their too diligent applica- 
tion ; for I cannot persuade myself but that most of the maiming in this 
case was due to the apparatus rather than to the original accident. 

This gentleman was injured on the 10th of November, 1855. A sling 
with an axillary pad and bandages was immediately applied. I saw him 




Mayor's apparatus for dislocated clavicle. 
("Triangle cubito-bis-scapulaire.") 



OF THE ACROMIAL END OF CLAVICLE DOWNWARDS. 629 

on the seventeenth day. The displacement was then such as I have de- 
scribed, but I did not observe any paralysis or emaciation of the limb. 
Having noticed that the clavicle fell into its socket when he lay upon his 
back in bed, at my suggestion all the dressings except the sling were 
removed, and the patient laid upon his back in bed, with instructions to 
continue in this position, if possible, until the cure was complete ; but 
after a few days I received a communication from his physician, stating 
that, owing to a troublesome cough, he had found it impossible to main- 
tain this position. His residence was forty or fifty miles from town, and 
I sent him one of my dressings for broken collar bones with instructions 
as to its use ; directing especially that a shoulder-strap should be used 
to keep the clavicle down. 

The dressing was applied and continued six weeks, and on being re- 
moved, the elbow, wrist, and finger-joints were found to be stiff. The 
whole arm was emaciated and almost powerless. One year later there 
was no improvement in the condition of the arm ; every joint from the 
shoulder down was almost completely anchylosed, the muscles were greatly 
wasted, and the hand trembled constantly. 

These results, it seems to me, were due to too long and too tight band- 
aging of the arm, and especially to the pressure of the axillary pad. I 
do not state this positively, but this is my belief. 

Is it worth while, then, to incur the dangers of too long confinement 
and of excessive bandaging for the purpose of attaining the always un- 
certain result of maintaining the bone in its socket ? We certainly may 
be permitted to make the attempt within certain reasonable limits : and 
especially if the patient is a female and the avoidance of deformity is a 
point of serious consideration ; but never without keeping constantly in 
mind the possibility of a permanent anchylosis and paralysis of the limb. 

(b) Dislocation of the Acromial End of the Clavicle Downwards. 

This form of dislocation is exceedingly rare, only four well-authenti- 
cated cases are known to me as having been placed upon record, one of 
which was seen and dissected by Melle in 1765, the second was met with 
by Fleury in 1816, and the third is described by Tournel. 

Dr. Walter B. Chase, of Brooklyn, N. Y., has reported a case in a 
boy 8 years old, who fell headforemost Aug. 15, 1877, twelve or fifteen 
feet, striking the top of his shoulder upon the round of a ladder. The 
patient was thin, and the exact position of the clavicle was easily traced. 
The axis of the bone was changed, carrying the acromial end downwards 
and a little backwards. The anterior portion of the shoulder was flat- 
tened, and the acromion process was very prominent. He could move 
the arm slightly when it hung by his side. 

The boy was anaesthetized, and the reduction easily effected " by 
throwing the shoulder outwards and backwards, Avhile at the same time 
I grasped the clavicle in its outer third with the extremities of my fingers 
and thumb, and carried it upwards and forwards into its normal position. 
There was no subsequent tendency to displacement." 1 

1 Chase, Transactions Med. Soc. State of New York, 1879, p. 174. 



630 DISLOCATIONS OF THE CLAVICLE. 

Cause. — So far as we can ascertain, it has been produced only by a 
force which has acted directly upon the top of the clavicle. In the case 
mentioned by Tournel, a horse had trod upon the shoulder ; and in the 
example recorded by Melle, the accident occurred in a child six years 
old, from an attempt to support a great weight upon the top of the collar- 
bone. In this last example the humerus was dislocated also, and both 
dislocations had remained unreduced many years when the patient was 
seen by Melle. 

This force acting directly upon the top of the clavicle would fail to 
dislocate the bone, except by first breaking down the coracoid process, 
if it did not happen sometimes that at the same moment the lower angle 
of the scapula was thrown outwards, in such a manner as to depress 
slightly the coracoid process, and thus to permit the outer end of the 
clavicle to fall below the level of the acromion process. 

Symptoms and Pathology. — This dislocation, whether it has been pro- 
duced artificially upon the dead subject or accidentally upon the living, 
has always been found to be accompanied with a complete rupture of the 
acromio-clavicular ligaments not only, but also of the coraco-acromial and 
coraco-clavicular ligaments ; the outer extremity of the bone resting be- 
tween the acromion process and the capsule of the shoulder-joint, and a 
little posterior to the articulating facet which originally received the 
clavicle. 

The superior angle of the scapula approaches the body slightly, and 
its inferior angle is thrown outwards. A marked depression exists at 
the point of dislocation, accompanied with a sharp pain, increased espe- 
cially when an attempt is made to move the arm. The patient is unable 
to lift the arm voluntarily, but it can be moved pretty freely in the direc- 
tion forwards and backwards by the hands of the surgeon ; abduction is 
much more difficult. 

Treatment. — Reduction is easily accomplished. At least, in the only 
three examples upon the living subject in which the attempt has been 
made, it was effected promptly by drawing the shoulders outwards and 
backwards ; nor has it been found any more difficult to maintain it in 
position when once replaced. When the scapula is restored to its natu- 
ral position, and its lower angle approaches again the side of the body, 
a reluxation becomes impossible ; since the coracoid process now effectu- 
ally prevents that descent of the clavicle upon which its displacement 
always depends. It is only necessary, therefore, to secure the scapula 
at its base and lower angle snugly to the body, by a broad band and 
compress, and all the indications of treatment are completely fulfilled. 

(c) Dislocation of the Acromial End of the Clavicle under the 

Coracoid Process. 

Pinjou met with one example of this singular dislocation, 1 and Gode- 
mer, of May enne, has recorded five more, 2 and these constitute the whole 
number which are at this day know r n to science. 

1 Pinjou, Journ. de Med. de Lyon, Juillet, 1842, from Vidal (de Cassis). 

2 Godemer, Recueil dts travaux de la Soc. Med. d'Indre et Loire, 1843, from Vidal. 



DISLOCATION OF CLAVICLE AT BOTH ENDS. 631 

Cause. — Age and a consequent relaxation of the ligaments seem to 
constitute a predisposing cause, since of the six recorded examples four 
were between the ages of sixty-seven and seventy-one, and the other two 
were adults. In all the cases, also, the dislocations were the results of 
falls upon the shoulder. 

The symptoms which have been said to characterize this accident are 
pain and a very marked depression at the point of displacement, with a 
corresponding projection of the acromion and coracoid processes ; a rapid 
inclination outwards and downwards of the line of the clavicle, its outer 
extremity being felt in the axilla ; the corresponding shoulder depressed 
and inclined forwards ; freedom of motion in all directions except inwards 
and upwards ; the lower angle of the scapula thrown outwards and back- 
wards ; to which Morel-Lavallde has added an actual increase of space 
between the acromion process and the sternum. 

Treatment. — Godemer reduced all the examples which came under his 
notice easily, by directing an assistant to pull the arm backwards and 
outwards while he himself seized upon the clavicle with his fingers, and 
disengaged it from under the process ; but Pinjou, after many efforts by 
the same method, failed completely, and the patient having left him, the 
clavicle was reduced the next day by an empiric. Vidal (de Cassis) 
recommends that instead of pulling the arm outwards, by which proced- 
ure the pectoralis major is made to antagonize the surgeon, the elbow 
shall be brought down to the side, and kept there by the left hand, 
while the right hand, placed in the axilla, shall pull the upper end of 
the humerus outwards, converting the arm into a lever of the third kind. 
This 'process, I confess, seems to be much the most rational. 

Finally, having given the history of these cases as they have been 
reported, we shall scarcely have performed our duty as a faithful writer 
if we do not state frankly that we entertain a suspicion that both the 
gentlemen who have reported these curious examples have entertained us 
with fabulous or imaginary stories ; and especially do these suspicions 
rest upon the cases reported by Godemer, who in five years saw five 
cases, each presenting throughout the same class of symptoms, the same 
facility of reduction, accomplished by the same means, and always with 
the same perfect result. 

If to these singular coincidences we add the fact that only one other 
surgeon has ever claimed to have met with the accident, and if we notice 
the actual anatomical difficulties which stand in the way of its occur- 
rence, such especially as the complete occlusion of the subcoracoidean 
space by the tendons and muscles which pass from its extremity toward 
the chest and arm, we shall find a fair apology for some degree of skep- 
ticism. 

(d) Dislocation of the Clavicle at both Ends, simultaneously. 

On the 26th of January, 1863, Dr. Xorth, of Brooklyn, N. Y., was 
called to see a lad fourteen years of age, who had been thrown with vio- 
lence backwards from a stool upon which he was sitting, striking the 
back of his left shoulder against the floor. Dr. North found him suffer- 
ing severely from pain, and with some difficulty of breathing. The 



632 DISLOCATIONS OF THE CLAVICLE. 

shoulder was depressed and thrown forwards. The sternal end of the 
clavicle, turned forwards, formed an abrupt, rounded prominence : the 
acromial end, turned forwards also, presented its longest diameter toward 
the surface, and rested above the acromion process ; while the central 
portion seemed depressed or thrown back, an appearance which was 
caused by the rotation of the clavicle upon its axis. 

Reduction was accomplished by throwing the shoulders forcibly back- 
wards, and at the same time pressing with the thumbs upon the two ex- 
tremities in such a manner as to reverse the rotation, as follows : press- 
ing at the acromial end backwards and downwards, and at the sternal 
end backwards and upwards. The restoration was complete, and the 
bones were retained in place by compresses and adhesive plaster, with 
the aid of Day's " neck yoke." At the end of three weeks the dress- 
ings were removed ; and when last seen by his surgeon " there was but 
little, if any, trace of the accident remaining." It is the opinion of Dr. 
North that the rotation was caused by the action of the pectoralis major 
and deltoid after the dislocation took place. 1 

Erichsen says that Richerand and Morel- Lavalle'e have each reported 
one example of double dislocation of the clavicle. 

Dr. Stanley Haynes, of Malvern Link, has reported the only remain- 
ing case of which I have been able to find a record. 

u A girl, aged 13, rapidly growing, of lax tissues, and of a consump- 
tive family, but who had always had good health, while washing the 
back of her neck with her left hand, one morning in September, felt 
something give way in the shoulder of the same side. I found disloca- 
tion forwards of the sternal end of the clavicle and partial luxation 
upwards of the acromial one. There was very little pain. Both ex- 
tremities of the bone were easily replaced by drawing the shoulder 
backwards and downwards, but the double deformity was reproduced 
immediately the shoulder was liberated. A pad was applied under a 
figure-of-8 bandage over the sternal end, and the arm was placed in a 
sling as a temporary measure. To a strap, fastening round the chest, 
a strap bearing a truss-pad was attached in such a manner that the pad 
kept the sternal end of the clavicle reduced, the other end of the strap 
passing over the shoulder and diagonally across the back to the hori- 
zontal strap : the wearing of a sling kept the acromial end in its natural 
position. The patient soon afterwards returned to school at a distance. 
She is now at home, and I have found the sling has been discontinued 
some time, that the straps have stretched and are useless, and that the 
ends of the bone are as mobile as, but not more than, they were when I 
first saw the patient, but that the sternal end does not become luxated 
unless the arm is raised, when it nearly always starts forwards." 2 

• N. L. North, M.D., New York Med. Record, April 16, 1866. 
2 The British Medical Journal, Jan. 27, 1872. 



DISLOCATIONS OF THE SHOULDER. 633 



CHAPTER VI. 

DISLOCATIONS OF THE SHOULDEK (SCAPULO-HUMERAL). 

Owing to the great exposure and the peculiar anatomical structure 
of the shoulder-joint, its structure having reference mainly to freedom 
of motion rather than to firmness and security in the articulation, dislo- 
cations of the humerus are very common. 

My private and hospital records furnish me with 117 cases of disloca- 
tion of the shoulder, seen and recorded by myself. Of these, 41 were 
recognized as subglenoid, 33 as subcoracoid, a very small proportion as 
subclavicular, 2 as subspinous, and the remainder were not accurately 
diagnosticated. 

Writers have not been agreed as to the precise anatomical relations 
of these dislocations, nor as to the nomenclature. Velpeau, Malgaigne, 
Vidal (de Cassis), Skey, and Sir Astley Cooper have each adopted ex- 
planations and classifications peculiar to themselves. With the arrange- 
ment established by this latter surgeon, English and American students 
are the most familiar ; and believing that it is more simple, and quite as 
appropriate as either of the others, I shall adopt it as the basis of my 
own descriptions. 

I shall have occasion, however, to dissent from the opinions and 
teachings of this distinguished surgeon, as to the exact seat and rela- 
tions of the head of the humerus in some of these dislocations. 

According to Sir Astley Copper, there are three complete luxations 
of the shoulder ; namely, downwards, forwards, and backwards. 

The so-called " supra-coracoid" dislocation, recognized by Malgaigne, 
and of which Malgaigne, Holmes, and Hewitt have each reported an 
example, is not admitted by me as constituting properly one form of 
shoulder-joint dislocation, inasmuch as its occurrence renders necessary 
a fracture of the coracoid process. 1 

§ 1. Dislocation of the Shoulder Downwards (Subglenoid). 

This is usually called a dislocation into the axilla ; the head of the 
bone resting rather upon the inner side of the inferior border of the 
scapula, near the base of that triangular surface which is found below 
the glenoid fossa. 

Since in both the other complete dislocations of the shoulder, the 
head of the humerus, in order to escape from its socket, must be made 
to descend more or less downwards, ive shall regard this dislocation as 
the type of all the others, and shall make it the subject of especial con- 

1 Holmes's Surg., 2d Lond. ed., vol. ii. p. 820. 
41 



634 DISLOCATIONS OF THE SHOULDER. 

sideration as well as of reference when speaking of the other forms of 
dislocation. 

Causes. — The most frequent cause of this accident is a blow received 
directly upon the upper end and outer surface of the humerus. I have 
found the arm dislocated into the axilla by this, cause thirty-one times ; 
five times by a fall upon the extended hand ; three times by a fall upon 
the elbow ; and in these latter cases the arm was probably carried away 
from the body at the moment of the receipt of the injury. 

In all the above examples the shoulder has been dislocated by the 
simple force of the blow, or with only slight aid from muscular action ; 
but in a considerable number of cases the bone is displaced almost 
wholly by the action of the muscles, the arm having been previously 
violently abducted ; and perhaps in some cases the capsule being torn 
before the resistance of the overstrained muscles has accomplished the 
displacement. Thus, in three instances I have known the dislocation 
to result from holding on to the reins after being thrown from a car- 
riage ; in two cases the patients have fallen through a hatchway and 
been caught and suspended by the arms ; once a woman met with this 
accident by holding on to a pump-handle when she had slipped and 
fallen upon the ice. A few years since I examined the arm of a Swiss 
woman, Maria Norregan, who was then sixty-five years old, and whose 
humerus had been dislocated into the axilla seventeen years before, 
where it still remained. Her own account of the accident was, that she 
was returning from the Jura Mountains, near Neufchatel, with a load of 
hay upon her head. She had carried it a long way with her hands held 
upwards, without once stopping to rest, and when at length she threw 
down the load at her door, the right shoulder was dislocated. The arm 
soon became very painful, and swollen to the fingers' ends ; but she 
was too remote from, and too poor to employ, a surgeon. A tailor, who 
used to do the minor surgery of the neighborhood, bled her three or four 
times, but the dislocation was not recognized until many months after. 

A Mrs. Hunn informed me that when she was twenty-two years old 
she had a convulsion, and that her attendants in trying to hold her 
upon her bed, actually pulled the shoulder out of joint. After the first 
accident the dislocation was not repeated for four years, but since then 
it had occurred from very slight causes many times. She was in the 
habit of reducing it herself by placing a ball in the axilla and using the 
arm as a lever. 

Dr. Lehman reports the case of a sailor on board an American brig, 
who was subject to a dislocation into the axilla from very slight causes, 
and especially if he bent his body far over to raise anything. He could 
also, by pulling horizontally, remove the head of the bone from its 
socket. It was reduced easily, and he experienced no pain either in the 
reduction or dislocation, nor, indeed, during the displacement. 1 

Pathology. — In this accident the head of the bone is made to press 
against the capsule below and immediately in front of the long head of 
the triceps, until the capsule gives way, and continuing to descend in 
the same direction it is finally arrested by the triangular surface of the 



» Lehman, Amer. Journ. Med. Sci., vol. i. p. 242, 1828. 



DISLOCATION OF THE SHOULDER DOWNWARDS. 



635 



Fig. 261. 



inferior edge of the scapula immediately below the glenoid fossa. Owing 
to the pressure of the tendon of the triceps behind, it occupies a position 
also a little in advance of the centre of this triangle, or rather upon its 
anterior edge, so that it rests more or less upon the belly of the sub- 
scapularis muscle. 

The capsule is generally torn quite extensively, especially below and 
in front ; and the tendon of the long head of the biceps may be broken 
asunder, or detached completely 
from its insertion ; the supra- 
spinatus muscle is stretched or 
lacerated; the infra- spinatus, 
subscapularis, and coraco-bra- 
chialis are put upon the stretch ; 
the subscapularis being also some- 
times completely torn from its 
attachment to the head of the 
humerus, and in either case, 
whether torn or merely com- 
pressed and stretched, the cir- 
cumflex nerve, which runs along 
its lower margin, is subject to 
severe injury; the deltoid muscle 
is also placed in a condition of 
extreme tension; while the teres 
major and minor in this re- 
spect are subjected to but little 
change. 

In some cases a portion or the 
whole of the greater tuberosity 
is completely detached, and the fragment displaced by the action of the 
muscles inserted into it. 

In one case the axillary artery has been ruptured. The patient had 
been thrown down by a runaway horse, and was taken to Jervis Street 
Hospital, London. On the tenth day Surgeon O'Reily tied the sub- 
clavian artery, and the patient recovered after the loss of two fingers 
from erysipelas and gangrene. 1 

With more or less rapidity, after the occurrence of the dislocation, if 
the bone remains unreduced, various changes take place in the anatomi- 
cal relations and structure of the parts. The following is a brief account 
of the condition in which the parts were found in the case of an old man, 
whose history is unknown. The dissection was made by my assistant 
Dr. Frank Deems, at the Bellevue dead-house. The head of the hume- 
rus was in front of the socket, below the coracoid process, lying upon 
the anterior surface of the neck of the scapula. A new socket was 
formed in the bone at this point, mostly cartilaginous, and a fibrous cap- 
sule inclosed the head of the humerus. The margins of the old socket 
were removed, and the socket was filled with fibrous tissue. The axil- 
lary nerves and artery were not injured or compressed. The biceps 




Dislocation of the shoulder downwards into the 
axilla. (Subglenoid.) 



Todd's Cyclop. Anat. and Surg., p. 616 ; Holmes's Surg. vol. ii. p. 827. 



636 



DISLOCATIONS OF THE SHOULDER. 



tendon was not torn. All the muscles about the shoulder were 
atrophied. 

Symptoms. — A palpable depression immediately under the extremity 
of the acromion process, more distinct in children, in very old and in 
thin people, than in adults of middle life or than in fat or muscular 
people, but never absent completely, unless the shoulder is very much 
swollen ; the elbow carried out from the body three or four inches, 

Fig. 262. 




Dislocation of the shoulder downwards into the axilla. (Subglenoid.) 

sometimes a little backwards, and the line of its axis directed toward 
the axilla ; the outer surface of the arm presenting two planes inclined 
toward each other, and meeting at the point of insertion of the deltoid 
muscle ; the head of the humerus felt in the axilla, particularly when 
the elbow is carried away from the body ; numbness of the arm, accom- 
panied generally with pain, especially when any attempt is made to 
press the elbow against the side ; rigidity with inability to move the 
arm freely in any direction, but especially inwards ; allowing, however, 
of pretty free passive motion, but not permitting the elbow to touch the 
body without great pain, which pain is occasioned mostly by the pres- 
sure of the humerus upon the axillary plexus ; under no circumstances can 
the hand be placed upon the opposite shoulder while at the same moment 
the elbow touches the thorax ; the head of the patient, and sometimes 
the w T hole body, inclined toward the injured arm ; the arm lengthened 
from half an inch to an inch ; a chafing or friction sound is not unfre- 
quently present, especially if the bone has been some days dislocated ; 
but Mr. Lawrence mentions a case in which there was a distinct crepitus, 
yet there was no fracture ; Dr. Hays saw a similar case in Wills Hos- 
pital, Philadelphia, in a woman sixty years old, whose arm had been 



DISLOCATION OF THE SHOULDER DOWNWARDS. 637 

dislocated forwards eight weeks. 1 Other surgeons have related like 
examples, but it is probable that in all these cases there has been an 
exposure of the bone at or near the edge of the glenoid fossa, by the 
partial detachment of its ligamentous margin, or some portion of the 
head has become divested of its cartilaginous covering. (For a more 
complete differential diagnosis, see chapter on Fractures of the Humerus.) 

Decisive as these signs usually are of the true nature of the accident, 
cases will every now and then occur in which the diagnosis will be 
attended with great difficulty, and especially if a few hours have been 
permitted to elapse since the occurrence of the injury, so that consider- 
able effusions of blood and of lymph may have taken place ; while at a 
still later period, when the swelling has subsided, the diagnosis again 
becomes easy. "At this latter period," says Sir Astley Cooper, " it is 
that surgeons of the metropolis are usually consulted ; and if we detect 
a dislocation which has been overlooked, it is our duty in candor to state 
to the patient that the difficulty of detecting the nature of the accident is 
exceedingly diminished by th.e cessation of inflammation, and the absence 
of tumefaction." 

In a rapid review of the cases of dislocation of the shoulder which 
have come under my notice, I find thirteen subglenoid and ten subcora- 
coid dislocations which were not recognized as such by the surgeons first 
called. Some were mistaken for fractures, and some were called contu- 
sions or sprains. And among the surgeons who fell into these errors 
are some of our oldest and most experienced hospital surgeons. I have, 
however, seen many more unrecognized and unreduced dislocations of 
the shoulder than are mentioned above ; but the frequency with which I 
have met with them must not be regarded as representing the usual ratio 
of these errors of diagnosis in general practice, inasmuch as the majority 
of them were examples in which the patients or the surgeons have con- 
sulted me for advice. 

It is due to science, if not to myself, to say that it has never happened 
to me to have seen a case of dislocation of the shoulder which'I have not 
recognized. Although, therefore, I am prepared to admit the justness 
of the observations made by Sir Astley Cooper, I think that errors in 
diagnosis are often due to carelessness, or to a lack of experience, or to 
an insufficient study of the well-established rules of diagnosis. Upon 
this subject I have already spoken very fully in the chapter on fractures 
of the humerus ; and from the examples and opinions which I have there 
presented it will be inferred that it is much more common to mistake a 
fracture for a dislocation, than a dislocation for a fracture, an observa- 
tion which is equally as applicable to dislocations forwards as to the form 
of dislocation now under consideration. 

Prognosis. — If the force which displaced the bone was not great, or 
if the shoulder-joint has not suffered any injury from the accident itself 
beyond the mere rupture of the capsule and a moderate straining of the 
muscles, and if the dislocation has been early and easily reduced, the 
patient is immediately after the reduction able to move the arm freely in 

1 Lawrence, Hays, Amer. Journ. Med. Sci., vol. xxiv. p. 236, May, 1839. 



638 DISLOCATIONS OF THE SHOULDER. 

all directions ; very little swelling follows, and in a short time a perfect 
restoration of all the functions of the limb is accomplished. 

It cannot, however, always be inferred from the degree of violence 
employed in the production of the dislocation, nor from the absence or 
presence of swelling, how much injury the tendons, muscles, and nerves 
have suffered, since the same causes produce greater lesions in one per- 
son than in another, and the amount of swelling may depend upon the 
accidental rupture of an unimportant bloodvessel, or upon some pecu- 
liarity in the constitution of the patient predisposing to serous, fibrous, 
or sanguineous effusions. 

To whatever cause we may find occasion to attribute the result, it will 
nevertheless be observed, that, in a great majority of cases, the limb is 
not restored to all its original strength and freedom of motion until after 
the lapse of some months ; and the shoulder does not resume its perfect 
form and symmetry until a much later period ; occasional pains, espe- 
cially after exercise of the muscles, and in certain conditions of the 
weather, are present also at irregular intervals and for indefinite periods 
of time. Opposite and more favorable terminations must be regarded as 
exceptions to the rule. 

Where the reduction has been made within a few hours, I have 
found the shoulder affected with muscular anchylosis with more or 
less weakness of the arm after a lapse of from a few days to one or two 
years. 

A laborer, set. 41, had dislocated his right shoulder into the axilla. 
Dr. H., an intelligent young surgeon, reduced the bone easily with his 
hands alone, while the patient was still unconscious from the shock of 
the injury. After six weeks he called upon me, accompanied by his 
surgeon, thinking that it was not properly reduced because the arm was 
still painful, and he could not move it freely. The bone was, however, well 
in its socket. One year later I examined this man, and found some an- 
chylosis remaining in the shoulder-joint. 

James Rogers, aet. 39, fell while running, and struck upon his right 
shoulder. Dr. Eastman, Professor of Anatomy in the Buffalo Medical 
College, reduced the dislocation four hours after the occurrence, in the 
following manner: The patient being seated in a chair, Dr. Eastman 
placed his knee in the axilla and manipulated, while one assistant sup- 
ported the acromion process, and another pulled downwards upon the 
forearm. The time occupied in the reduction was about two minutes, 
and the bone finally resumed its position with a snap audible to all the 
persons in the room. For some months after, and at the period when I 
was invited to see him, the muscles about the shoulder were rigid, and 
the motions of the joint embarrassed ; but at the end of two years, Dr. 
Eastman informed me that the joint had become free and the arm as 
useful as before, except that he could not throw a stone. 

In another case, a gentleman residing in an adjoining county, aet. 42, 
was thrown from his carriage, falling forwards upon his hands. The 
dislocation was reduced promptly, by placing the heel in the axilla, and 
within fifteen minutes after it had occurred. Three months after this the 
patient consulted me on account of the immobility of the shoulder-joint, 
and because several surgeons had expressed a doubt whether it was 



DISLOCATION OF THE SHOULDER DOWNWARDS. 639 

properly reduced. The anchylosis was then so complete that the humerus 
could not be moved separately from the scapula, but there was no dis- 
placement. This gentleman again called upon me at the end of four 
years, and I then found the arm nearly restored to its original condition, 
but it was not quite so strong as before. He experienced also "curious" 
sensations in his arm and hand occasionally. The anchylosis had con- 
tinued with very little improvement about two years, after which it had 
been gradually disappearing. 

I need scarcely say that in those examples in which the reduction of 
the bone has been delayed beyond a few hours, or for several days or 
weeks, the continuance of the anchylosis has been more persistent; but 
in no case which has come under my observation, unless the bone still 
remained unreduced, has the anchylosis been permanent. For this reason 
I am disposed to think that muscular, rather than fibrous or ligamentous 
anchylosis, is the cause, generally, of the immobility of the joint. I 
have certainly never in any instance met with a true bony anchylosis as 
a consequence of a shoulder dislocation. The anchylosis in question 
seems to be a result simply of laceration or more generally of a severe 
strain of the muscular fibres, resulting in inflammation and a contraction 
of these fibres; and its occurrence in any particular case may therefore 
be justly attributable either to the position of the bone when it is dislo- 
cated, to the force of the blow which has produced the dislocation, or to 
the violence applied in the attempts at reduction. 

Paralysis and wasting of the muscles of the arm, either with or without 
muscular contraction and rigidity, are also observed in a certain number 
of cases. Especially has it been noticed that the deltoid muscle is liable 
to atrophy ; and in their attempts to explain the frequency of its occur- 
rence in this latter muscle, surgeons have generally referred to a probable 
rupture of the circumflex nerve, a circumstance which the autopsies show 
does occasionally take place ; or to a mere stretching of this nerve ; yet 
it is quite as fair to presume that in many cases it is due solely to the 
greater injury which the deltoid muscle has sustained by the unnatural 
position of the head of the bone during the continuance of the dislo- 
cation, for, with the exception of the supra-spinatus, it is placed more 
upon the stretch than any other. Nor is it improbable that in some 
cases it is due to the mere force of the blow which, having been directly 
upon the top of the shoulder, has contused the muscle. In short, any 
of the causes which may determine in the deltoid inflammation and con- 
sequent rigidity, must finally result in desuetude and consequent atrophy. 

In the case of an adult, P. Madden, who consulted me in June, 1874, 
there was slight atrophy and paralysis of the deltoid, and almost com- 
plete atrophy of the supra-spinatus, with much anchylosis, due, I think, 
to prolonged efforts at reduction. 

In quite a number of cases my attention has been called to a remark- 
able fulness just in front of the head of the bone, which has continued 
sometimes for many months and even years after the reduction has been 
effected; the patients having in several cases applied to me to know 
whether this did not indicate that the bone was not in its socket, espe- 
cially as it has been usually attended with some stiffness in the joint. 
Not unfrequently I have been told that surgeons who had noticed this 



640 DISLOCATIONS OF THE SHOULDER. 

fulness, thought the bone was not reduced; and in one instance I am 
informed that a jury returned a verdict against the surgeon, where there 
was no other evidence of malpractice than this fulness with some anchy- 
losis, but which, in the opinion of some medical gentlemen who testified, 
was conclusive evidence that the bone was not properly set. The decep- 
tion is also often the more complete from the fact that there may exist a 
corresponding depression underneath the acromion process, behind. 

These phenomena may be present where but little force has been used, 
either in the production of the dislocation or in its reduction. I have seen 
it in a girl, only fourteen years of age, who had dislocated her left shoulder 
into the axilla, by a fall upon a slippery sidewalk. I reduced the bone, 
assisted by Dr. George Burwell, within half an hour after the accident. 
Dr. Burwell held upon the acromion process while I lifted the arm to a 
right angle with the body, and pulled gently, and the reduction was at 
once accomplished ; but we immediately noticed that the head of the 
bone seemed to press forwards in the socket so as to resemble what Sir 
Astley Cooper has described as a partial forward luxation. There was 
also a corresponding depression behind. Carrying the elbow back ren- 
dered the projection more decided, but bringing it forwards would not 
make it entirely disappear. 

In other instances where the deformity in question has been present, 
more force has been employed in the reduction. A man weighing two 
hundred pounds, and forty-one years of age, residing at Bath, in Steuben 
Co., fell from a load of hay in May, 1853, striking upon the top and 
front of the left shoulder. It was immediately ascertained that he had 
dislocated his arm into the axilla, and broken his leg. A young surgeon 
attempted within a few minutes to reduce the dislocation, but failed ; and 
about two hours later it was reduced by another surgeon, with the aid 
of chloroform and Jarvis's adjuster. Four years after the accident had 
occurred, this gentleman came to me accompanied by the surgeon who 
had made the reduction, in consequence of its having been intimated by 
some medical men that it was not properly reduced. The arm was not 
as strong as the other; some anchylosis existed at the shoulder-joint; 
but especially it was noticed that there still remained a remarkable ful- 
ness in front, as if the head of the bone was pressed forwards. By no 
manipulation or position could this fulness be made to disappear, yet the 
bone was plainly enough in its socket. 

This phenomenon is probably due in some cases to a rupture of the 
supraspinatus muscle, and the consequent preponderating action of the 
antagonizing muscles, or to the laceration of the capsule, but in others, 
I imagine, to a rupture or possibly to a displacement of the long head of 
the biceps, a circumstance to which I shall more particularly allude 
under the subject of "partial dislocations." 

Among the results of this dislocation must be placed a tendency to 
reluxation, which, although it may not often be made manifest by its 
actual occurrence, owing perhaps to the prudence of the surgeon, yet it 
does take place in a sufficient number of cases to establish its peculiar 
liability. Indeed, we need only consider how imperfect is the protection 
against this accident, when once the capsule has been torn, to appreciate 
this observation. Examples of spontaneous luxation, or of luxation of 



DISLOCATION OF THE SHOULDER DOWNWARDS. 641 

the shoulder from very trivial causes, after it once has been luxated, may 
be found in the "experience of almost every surgeon. I have myself met 
with several persons who have had repeated luxations from a slight cause ; 
and in some instances, where the patients were subject to epilepsy, the 
luxations have occurred whenever the convulsions returned. 

A gentleman residing at Toronto, Canada West, had a dislocation of 
the right shoulder into the axilla when he was quite a child, and the ac- 
cident was renewed when twenty -nine years old by falling from a carriage 
head foremost, with his right arm extended and uplifted. Since then, 
until he called upon me, a period of about six years, he has been con- 
stantly subject to the same dislocation ; and he cannot raise his arm high 
above his shoulders without producing a subluxation, the head of the 
humerus resting upon the outer margin of the lower and anterior edge 
of the glenoid fossa, but by rotating the arm outwards it immediately 
resumes its place. I found the whole limb as fully developed, and he 
said it was quite as strong, as the opposite limb. 

I have already mentioned the case of Mrs. Hunn, whose arm had been 
dislocated more than twenty times in the last five years ; and I remember 
a lad, Pat Dolan, aged nineteen years, whose left arm was dislocated by 
falling from the masthead of a vessel, and hanging by his hand. No 
attempt was made to reduce it until fourteen hours after the accident, at 
which time it was set by two German doctors, but not until they had 
pulled upon it three hours. Four months after, it was again dislocated 
by the slipping of an oar while he was rowing a boat. A surgeon hav- 
ing failed this time to bring it into place, I succeeded readily, and with- 
out the aid of an anaesthetic, by raising the arm directly upwards in the 
line of the body, while my foot was pressed upon the top of the scapula. 
Many other similar examples have come under my notice. 

We have referred more than once to the occasional difficulty of diag- 
nosis in this as well as in many other shoulder accidents. Other writers 
have mentioned many examples of unreduced dislocations of the shoulder, 
for which surgeons of skill and experience were responsible. I have 
myself, as before stated, met with these cases quite often. For example, 
I will mention here that I have seen two dislocations of the humerus into 
the axilla, both of which had been seen and examined by New York hos- 
pital surgeons within a few hours after the receipt of the injury, but the 
nature of the accident had not been recognized. One of these I reduced 
at Belle vue Hospital on the seventh day, and one on the tenth. There 
was also presented to me, at the Charity Hospital (BlackwelPs Island), 
in my service, an axillary dislocation of twenty years' standing, which 
a surgeon saw immediately after the receipt of the injury and failed to 
recognize. In other cases the dislocation has been clearly made out, 
but the surgeon has been unable to reduce the bone. It has been my 
fortune to succeed in several instances where others have made a fair 
trial and have failed, but the following case leaves me no opportunity to 
boast the superiority of my own skill above that of my confreres. 

Mary Kanally, aet. 49, a large, fat, laboring woman, was admitted into 
the Buffalo Hospital of the Sisters of Charity, with a dislocation of the 
right humerus into the axilla, which had occurred twelve hours before. 



642 



DISLOCATIONS OF THE SHOULDER. 



This is the same woman of whom I have before spoken as having pro- 
duced the dislocation by a fall while holding upon the handle of a pump. 
Drs. Lockwood and Baker, of Buffalo, were first called, and attempted 
reduction. They made extension and counter-extension in every possible 
direction, and for a long time, but to no purpose.. She was then sent to 
the hospital. Without attempting to describe minutely the various modes 
of extension and manipulation which I employed, I will briefly state that, 
having placed her completely under the influence of chloroform, the 
manipulations were made assiduously during one hour, without success. 
On the following morning she was bled freely from the opposite arm, and 
chloroform again administered ; extension being made, in the presence of 
Prof. Charles A. Lee and other gentlemen, with Jarvis's adjuster. After 
more than an hour, the effort was again suspended. On the following 
day we made a third attempt, the patient being completely under the 
influence of chloroform, but with no better success. The chloroform 
produced a condition approaching apoplexy, and it was not again used. 
On the tenth day, assisted by Prof. James P. White and other surgeons, 
we applied the compound pulleys, moving the arm in various directions. 
Twice we thought the reduction was accomplished, but as often as we 
proceeded to examine it attentively we found it was not. If it did ever 
pass into the socket, it was immediately displaced. 

The woman after this refused to submit to any further attempts, and 
she soon left the hospital, nor have I seen or heard from her since. 

Sir Astley Cooper has thus described the appearances presented on 
dissection of a dislocation which had been long unreduced : " The head 

of the bone altered in its form ; the sur- 
Fig. 263. face toward the scapula being flattened. 

A complete capsular ligament surround- 
ing the head of the os humeri. The gle- 
noid cavity entirely filled by ligamentous 
matter, in which were suspended small 
portions of bone, which were of new 
formation, as no portion of the scapula or 
humerus was broken. A new cavity 
formed for the head of the os humeri on 
the inferior costa of the scapula ; but this 
was shallow, like that from which the bone 
had escaped." 

When the dislocation into the axilla re- 
mains unreduced, the consequences are 
always sufficiently grave ; but they differ 
very much in degree, in character, and 
in persistence, according as the arm has 
remained a longer or shorter time unre- 
duced, and according to the presence or 
These conditions will be best illustrated by 




New socket 
the shoulder downwards 
Cooper.) 



an ancient luxation of 
(From Sir A. 



absence of complications. 
a reference to examples. 
Wm. S., a German, aet. 



51 



fell down a flight of steps while intoxi- 
cated, producing a dislocation of the left arm into the axilla. Eleven 
hours after the accident he was received into the Buffalo Hospital of the 



DISLOCATION OF THE SHOULDER DOWNWARDS. 643 

Sisters of Charity. No attempt had been made to reduce the bone. 
The reduction was effected by myself with tolerable ease, by extending 
the arm perpendicularly above the head, while my foot pressed upon the 
top of the scapula. The head of the humerus could be plainly felt in 
the axilla, approaching the socket, until it seemed to be directly over it, 
when, on lowering the arm, it was found to be reduced. • After the re- 
duction the patient could not raise the arm more than eight inches from 
the body. The fingers, hand, and forearm were almost paralyzed. 
Three weeks later, when he left the hospital, his arm had improved, but 
he could not flex his fingers. 

Mrs. G., set. 70, fell down a flight of steps and dislocated her arm 
into the axilla. She did not suspect the nature of the injury, and no 
surgeon was called. I was consulted one week after the accident, at 
which time she was suffering great pain from the pressure of the head 
of the bone upon the axillary nerves. We first attempted to reduce the 
bone by resting the knee in the axilla while she was sitting, but without 
success. We then placed her in bed, and with my knee in the axilla, 
the acromion process being supported by the hands of an assistant, we 
restored the bone after a few moments of pretty firm extension clown- 
wards and outwards. After the reduction she could not raise her arm, 
but the pain was much abated. One month later the arm remained very 
weak. She could not raise it more than six inches toward her head, but 
I could raise it to a right angle with the body without causing pain. 
The whole hand felt numb, and was occasionally painful. The deltoid 
muscle was slightly atrophied. There was also a slight flatness under 
the acromion process behind, and on the outer side, with a corresponding 
fulness in front. 

Mary Ann Hasler, set. 47, was admitted to the hospital with a dislo- 
cation of the right humerus into the axilla. The arm had been dislo- 
cated three weeks, in consequence of a fall upon the upper and outer 
part of the shoulder. An empiric, who saw it fifteen minutes after the 
fall, and when the arm was not swollen, said it was not dislocated. On 
the fifth day a Catholic clergyman discovered that it was out, and at- 
tempted to reduce it, but was not successful. When she came under my 
notice the arm was lengthened about one-quarter or one-half of an inch, 
and hung out from the body in a condition of almost complete paralysis. 
There was very little swelling about the shoulder or arm, and the head 
of the bone could be distinctly felt in the axilla. The patient being 
rendered partially insensible by chloroform, I placed my heel in the 
axilla, and pulling moderately about thirty seconds in a direction slightly 
outwards from the line of the body, the bone was reduced. Seven clays 
after the reduction she left the hospital, the arm being yet quite useless, 
though not greatly swollen. There was also a striking fulness in front 
of the head of the bone. 

Wm. Gardner, of Painted Post, N. Y., set. 75, dislocated the right 
humerus into the axilla, twenty years before I saw him, by falling upon 
his hands with his arms extended. I found the arm weak and atrophied, 
so that he could raise it but slightly outwards from his side ; he was un- 
able to move it forwards much beyond the line of his body ; but he could 



611 DISLOCATIONS OF THE SHOULDER. 

carry it back quite freely. The whole hand was in a condition of partial 
insensibility. 

I have before mentioned the case of Maria Norregan, the Swiss woman, 
whose arm had been dislocated downwards seventeen years. The deltoid 
muscle has become greatly wasted ; the head of the bone can be felt 
obscurely in the axilla; the arm is shortened perceptibly; the elbow 
hangs freely against the side ; the little and ring fingers are numb, and 
also one-half of the forearm ; the whole hand and arm are weak and 
atrophied ; she complains also occasionally of a troublesome sensation of 
formication over the arm and hand ; she cannot straighten her fingers 
perfectly; the elbow may be raised from the side to a right angle with 
the body, but she cannot raise it herself more than one foot ; she carries 
it back a little more freely than forwards. 

In compound dislocations the prognosis must always be regarded as 
exceedingly grave. In the only example which has come under my no- 
tice, the circumstances attending which I shall hereafter mention in the 
general chapter devoted to compound dislocations, the patient died from 
sloughing of the axillary artery. Mr. Scott has, however, reported a 
case, in a boy fourteen years of age, who recovered rapidly after the 
reduction was affected, and in thirteen months his arm was nearly as use- 
ful as before. 1 

Treatment. — The principles of treatment in this dislocation are very 
simple and easy to be comprehended. I speak now of recent uncompli- 
cated cases of dislocation into the axilla ; and, notwithstanding the various 
and sometimes almost contradictory views which surgeons have enter- 
tained as to the best and most rational modes of procedure, I continue 
to affirm that the laws which are to govern the reduction in a great ma- 
jority of cases are established and indisputable. 

Observe now the obvious anatomical facts, and then consider the in- 
evitable inferences. 

The capsule is torn, generally extensively, along the inner and lower 
margins of the socket. The head of the bone is lodged below and slightly 
in advance of its natural position, in consequence of which the points of 
origin and insertion of the deltoid muscle and the supra-spinatus are 
separated somewhat and their fibres rendered tense, insomuch that the 
arm is abducted and actually lengthened. 

At first, and in the most simple cases, these are the only muscles 
which are in a state of extreme tension, but after the lapse of a few 
hours, or of a few days, nearly all the other muscles about the joint, 
most of which were originally only in a condition of moderate extension, 
and some of which were rather relaxed than extended, sympathize with 
those which are suffering the most, and a general contraction and 
rigidity ensue, increased also at the last by the supervention of inflam- 
mation and its consequences. 

What, from these simple premises, must be the obvious practical 
deductions ? 

That in the simplest forms of the dislocation the most rational mode 

1 Scott, Anier. Journ. of Med. Sci., vol. xx. p. 515, Aug. 1837, from the London 
Lancet for March 4, 1837. 



DISLOCATION OF THE SHOULDER DOWNWARDS. 645 

of reduction will be to elevate the arm sufficiently to relax the over- 
strained deltoid and supraspinatus muscles, which bind the head of the 
bone in its new position, and to pull gently in the same direction, in 
order to overcome the moderate resistance offered by several other mus- 
cles, but whose tension cannot be relieved by the same manoeuvre. 

Failing in this, that we shall increase the relaxation of the first-named 
muscles, by pulling at a right angle with the body, or even directly 
upwards ; and meanwhile, as we carry the arm more and more upwards, 
we shall operate more powerfully against the resistance of the other 
muscles. 

If in all these modifications of the same procedure we keep the arm 
a little back of the axis of the body, we shall accomplish the indications 
the most perfectly. 

Such are the conclusions which must be drawn from the anatomical, 
or, as Mr. Pott would call it, the " physiological," argument ; and which 
assumes as its basis that the muscles constitute the sole or the main 
obstacle to the return of the bone to its socket. If any surgeon main- 
tains that the premise is unsound, and that the restoration of the head 
of the bone is opposed by the untorn fibres of the capsules or by any 
other important circumstance than the action of the muscles (we speak 
of ordinary cases), we shall content ourselves by referring him again to 
the extensive laceration which this capsule generally suffers, and to the 
constrained and almost uniform position of the arm, as a sufficient reply 
to his objection. 

It must not be forgotten that in all these modes of extension, for with 
nearly all of them some slight degree of extension is found necessary, 
there must be afforded some point of resistance beyond the bone; and 
this it is really which has constituted one of the greatest impediments to 
reduction. It is not that the muscles are in such an extraordinary state 
of extension or rigidity that they must be operated against with great 
force ; it is not that the margin of the glenoid fossa is an elevated bar- 
rier, like the margin of the acetabulum, over which the bone must be 
lifted before it can fall into its socket ; but the explanation of the diffi- 
culty so often experienced in producing effective extension and counter- 
extension is to be sought for mainly in the fact that the scapula, upon 
which the humerus rests, is movable, being held to the body by little 
else than muscles, which, in fact, bind the scapula much less firmly to 
the body than the muscles of the shoulder now bind the scapula to the 
arm ; while at the same time the scapula itself presents very few points 
against which a counter-extending force can be properly and efficiently 
applied. 

Occasionally it will be only necessary to elevate the arm to an acute 
angle, or to a right angle with the body, when, the resistance of the 
deltoid and supraspinatus being overcome, the bone will at once resume 
its place. In several instances which have come under my notice 
nothing more has been necessary ; and where it can be clone, the least 
possible pain and injury are inflicted. It is the method, therefore, 
which in all recent cases I have first tried and would wish to recommend. 
By it I have more than once succeeded when other and more violent 
efforts have failed. 



6±6 DISLOCATIONS OF THE SHOULDER. 

At other times it will be necessary to add to this simple manipulation 
only a moderate degree of extension, such as the hands of the surgeon 
can make, without the application of direct counter-extension except what 
is effected by the weight and resistance of the body. 

The late Dr. John T. Darby, Professor of Surgical Anatomy in the 
University, city of New York, informed me that he had been very suc- 
cessful in reducing dislocations of the shoulder, by adopting a rule similar 
to that which we have laid down for reducing dislocations of the thigh, 
namely, to carry the arm only in those directions in which it meets with 
the least resistance. He found that, in most cases, he could carry the 
arm up to nearly or quite a perpendicular, by humoring the action of 
the muscles; and that in this position the reduction was easily effected. I 
have no doubt that the principle, as stated by Professor Darby, is sound, 
and that in nearly all dislocations the same may be applied successfully, 
whenever we can depend upon manipulation alone. 

If, however, the bone refuse to move, w r e shall then be obliged to 
consider upon what point and by what means we can best apply a 
counter-extending force. Ample experience has taught me that the 
extremity of the acromion process is the only available point when we 
are making the extension in a line below a right angle, or in a line 
downwards more or less approaching the axis of the body. It has been 
supposed that the counter-extension could be made in the axilla against 
the inferior margin of the scapula ; but several obstacles are presented 
to the successful application of force at this point. The axillary space 
is narrow and deep, so that even with the ingenious contrivance of 
placing first a ball of yarn in the axilla, and upon this the heel of the 
operator, it will be found exceedingly difficult to enter the axilla without 
at the same time pressing with considerable force against ( its muscular 
margins ; but to press upon the pectoralis major and latissimus dorsi is 
to neutralize our own efforts. If, however, the heel or the ball does 
press fairly into the axilla, it will not find the scapula readily, but it 
must impinge first upon the head of the humerus, which is always a 
little to the inner side of the scapula. If it ever is made to reach 
actually the inferior border of the scapula, and I do not think it is, the 
effect must be still only to tilt the scapula upon itself by throwing back 
its lower angle, and not to separate the glenoid cavity or its upper and 
anterior margin from the head of the humerus. 

Whatever success, therefore, may have attended this mode of practice, 
either in my oivn hands or in the hands of other surgeons, must be 
ascribed not to the counter-extension thus effected, but simply to the 
operation of the heel as a wedge, which, by insinuating itself between 
the body and the head of the bone, has thrust it outwards and upwards 
into its socket ; or to its having acted as a fulcrum upon which the hume- 
rus has operated as a lever. 

It is to the extremity of the acromion process, then, that we must apply 
our counter-extension when we are employing this mode of extension. 
The fingers or hands of a faithful assistant may answer the purpose, or 
having removed his boot, the operator may often press successfully with 
the ball of his foot, and the more he carries the arm outwards, the more 
secure will be his seat upon the process ; or we may adopt some of the 



DISLOCATION OF THE HUMERUS DOWNWARDS. 



647 



contrivances for securing the process which have been suggested by other 
surgeons ; such as a band crossing the shoulder, and made fast to a coun- 
ter-band, which passes through the armpit and against the side of the 
body. Dr. Physick, of Philadelphia, reduced a dislocation in this way 
as early as the year 1790, in the case of a patient admitted to St. George's 
Hospital, in London, while he was a student of medicine, and he subse- 
quently taught the same in his lectures. Physick directed that an assist- 
ant should press firmly against the process with the palm of his hand. 
Dorsey and Hays approved of the same method, 1 and perhaps a majority 
of American surgeons regarded it favorably. 

If we pull directly outwards, at a right angle with the body, w T e may 
still continue to press upon the acromion process with the foot ; or we 
may perhaps trust to the method of making counter-extension, first sug- 
gested by Nathan Smith, of New Haven, and subsequently recommended 

Fig. 246. 




N. E. Smith's method. 



by his son, Prof. Nathan R. Smith, of Baltimore. Says Prof. N. R. 
Smith : 2 " What surgeon of experience has not encountered the diffi- 



1 Physick, Amer. Journ. Med. Sci., vol. xix. p. 386, Feb. 1837. Dorsey 's Elements 
of Surgery, vol. i. p. 214. Philadelphia, 1813. 

2 Smith's Med. and Snrg. Memoirs, Baltimore, 1831, p. 337; also, Amer. Journ. 
Med. Sci., July, 1861 ; also, American Med. Times, Nov. 9, 1861 ; paper by Stephen 
Rogers, M.D. 



648 DISLOCATIONS OF THE SHOULDER. 

culty which almost always occurs in fixing the scapula ?" and he then 
proceeds to give what seems to him the most effectual mode of rendering 
the scapula immovable, namely, to make the counter-extension from the 
opposite wrist. By this method the trapezii are provoked to contrac- 
tion, and the scapula of the injured side is drawn firmly toward the spine 
and the opposite scapula. In illustration of the value of this procedure 
he relates the case of a gentleman who had suffered a dislocation of his 
left shoulder, and upon whom an unsuccessful attempt at reduction had 
already been made by a respectable surgeon. Dr. Smith, being called, 
proceeded as follows : Two gentlemen made counter-extension from the 
opposite wrist, while Dr. Smith and Dr. Knapp made extension from the 
wrist of the injured side, at first pulling it downwards, but gradually 
raising it to the horizontal direction, and then gently depressing the 
wrist. On the effort being steadily continued for two or three minutes, 
the bone was observed to slip easily into its place. 

But no position places the scapula so completely under our control as 
that in which the arm is carried almost directly upwards, and the foot is 
placed upon the top of the scapula. By this method we may succeed 
generally when every other expedient has failed, yet it is painful ; and 
I cannot but think that it increases the laceration of the capsule, and 
that, even when employed in recent cases, it does sometimes serious in- 
jury to the muscles about the joint. In Lister's case of rupture of the 
axillary artery, and in Agnew's case of rupture of the axillary vein, both 
of which will again be referred to in connection with ancient dislocations, 
the accidents occurred when the arm was drawn upwards. La Mothe 
was the first to recommend this method, 1 but as early as the year 1764, 

Fig. 265. 




La Mothe's method, modified. 

Charles White, of Manchester, made fast a set of pulleys in the ceiling, 
and, placing a hand around the wrist of the dislocated arm, he drew the 
patient up until the whole body was suspended. No pressure, however, 
was made upon the scapula from above, which is no doubt the most essen- 

1 La Mothe, Amer. Journ. Med. Sci., vol. xix. p. 387, Nov. 1836, from Melanges de 
Med. el Chir., Paris, 1812. 



DISLOCATION OF THE HUMERUS DOWNWARDS. 



649 



tial part of the process. 1 By La Mothe's plan, Jobert succeeded after 
twenty-three days when all the usual methods had failed. 2 Sometimes 
this procedure is modified by placing the hand of the operator against 
the top of the scapula, as is shown in the accompanying drawing (Fig. 
265) ; and I have several times succeeded in this way after other meas- 
ures have failed. 

A gentle movement backwards or forwards, a slight rotation of the 
limb, or suddenly dropping the arm toward the body, diverting the atten- 
tion of the patient, are little tricks of the operator, which now T and then 
prove successful. 

Fig. 266. 




Sir Astley Cooper's method of applying extension with the heel in the axilla. 

Sir Astley Cooper thus describes his method of applying the heel to 
the axilla (Fig. 266): — 

" The patient should be placed in the recumbent posture, upon a table 
or sofa, near to the edge of which he is to be brought ; the surgeon then 
binds a wetted roller around the arm immediately above the elbow, upon 
which he ties a handkerchief; then he separates the patient's elbow 
from his side, and, with one foot resting upon the floor, he places the 
heel of his other foot in the axilla, receiving the head of the os humeri 
upon it, whilst he is himself in the sitting posture by the patient's side. 
He then draws the arm by means of the handkerchief, steadily, for three 
or four minutes, when, under common circumstances, the head of the 
bone is easily replaced ; but if more force be required, the handkerchief 
may be changed for a long towel, by which several persons may pull, 
the surgeon's heel still remaining in the axilla. I generally bend the 
forearm nearly at right angles with the os humeri, because it relaxes the 
biceps, and consequently diminishes its resistance." 

He was also accustomed in some cases to reduce the dislocation by 
substituting the knee for the heel. Placing the patient upon a low chair, 



1 C. White, Amer. Journ. Med. Sci., Nov. 1836, from Med. Obs. and Inquiries, vol. 
ii. p. 273, London, 1764. 

2 Ibid., vol. xxiii. p. 237, Nov. 1838. 

42 



650 



DISLOCATIONS OF THE SHOULDER. 



Fig. 267. 



the axilla is laid over the knee of the operator, and while one hand 
steadies the acromion process and scapula, the other presses downwards 

upon the lower end of the humerus 
(Fig. 267). 

If some hours or days have elapsed 
since the occurrence of dislocation, it 
will be necessary to resort to chloro- 
form or ether for the purpose of para- 
lyzing the muscles, as well as with the 
view of preventing pain ; and it may be 
necessary, in addition, to resort to pul- 
leys, or to some similar permanent 
mode of extension. The same mea- 
sures also sometimes become necessary 
in very recent cases, especially in mus- 
cular subjects. 

In employing the pulleys we gener- 
ally operate, not exactly in a line with 
the axis of the body, nor at more than 
a right angle, but between an angle of 
45° and a right angle. 

Mr. Skey has suggested a plan by 
which we may combine the principle of 
the heel in the axilla with the pulleys, 
but which plan would, in my judgment, 
be very much improved by a counter-extending force applied to the 
acromion process. I ought to say, however, that Mr. Skey prefers that 
the scapula should not be fixed, believing that the reduction is much 
more easily effected when the glenoid cavity is drawn downwards in the 
act of making the extension. 

With all respect for the opinion of this distinguished surgeon, we 
cannot precisely agree with him ; and while we would be disposed to 
recommend in some cases a trial of his method of applying the pulleys, 
we would, at the same time, or certainly in the event of its failure, add 
the acromial support, and especially would we advise that the arm 
should be more abducted. The following is Mr. Skey's method, as 
described by himself: — 

" There is no reason why, in very muscular subjects, or in old dislo- 
cations, the same principle may not be applied conjointly with the use 




Sir Astley Cooper's mode of operating with 
the knee in the axilla. 



Fig. 268. 




Iron knob employed by Skey, instead of the heel. 



of pulleys. For the purpose of retaining this admirable because most 
efficient principle, I employ a well-padded iron knob, which may repre- 
sent the heel, from which there extend laterally two strong straight 



DISLOCATION OF THE HUMERUS DOWNWARDS 



651 



branches of the same metal, each ending in a bnlb or ring of about four 
inches in length, the office of which is designed to keep the margins of 
the axilla as free from pressure as possible." The iron knob is to be 
pressed well up into the axilla and attached to cords fastened to a staple ; 
the patient lying upon his back or inclined a little to the opposite side. 
The arm is then to be drawn downwards by the pulleys, " as nearly as 
possible parallel to, and in contact with, the body." 1 

Fig. 269. 




Skey's method of making extension and counter-extension with pulleys. 

In this way Mr. Skey says that he has succeeded in reducing a great 
many dislocations, even when occurring in very muscular men, and after 

Fig. 270. 




Sir Astley Cooper's mode of making extension "with pulieys. 

some days', weeks', or even months' duration; and he thinks the plan 
especially applicable to cases which require long and persistent exten- 
sion. 



Skey, Operative Surgery, Amer. eel., p. 93. 



652 DISLOCATIONS OF THE SHOULDER. 

Mr. Skey and many other surgeons prefer to make the extension from 
the hand. I have succeeded as well, and it seemed to be less painful to 
my patients, when I have followed the practice of Sir Astley, and made 
the extension from the arm. Sir Astley always made the extension 
more or less out from the line of the body, and generally almost at a right 
angle when using the pulleys; the scapula being made fast by " a girt 
buckled on the top of the acromion," or by a split cloth (Fig. 270). 

The instrument invented by Dr. Jarvis, of Portland, Conn., called the 
adjuster, useless and even mischievous as we have found it in its appli- 
cation to the treatment of fractures, possesses considerable merit as an 
apparatus for reducing old dislocations, especially of the shoulder. The 
principal advantage which may be claimed for it is, that while the forces 
are being applied the limb may be moved pretty freely in all directions ; 
thus enabling us to employ rotation at the same time that extension is 
made. We may also lift or depress, adduct or abduct the limb without 
relaxing the extension. In the hands of American surgeons it has occa- 
sionally been successful when other means have failed. Dr. Jarvis has 
related a case presented at the Marine Hospital, at Mobile, Alabama, of 
forty-two days' standing, which he reduced on the second attempt, after 
other means had failed ; l and Dr. May, of Washington, reduced a similar 
dislocation at the end of six weeks, by the same apparatus, without, 
however, having previously resorted to any other means. 2 

I have myself used the apparatus occasionally, both in my hospital 
and private practice, and can speak favorably of its operation. 

I must not omit to mention the practice adopted by Prof. H. H. Smith, 
of Philadelphia, according to whom nearly all dislocations of the shoul- 
der, of a recent date, may be promptly and easily reduced by manipula- 
tion alone. His method consists, first, in flexing the forearm upon the 
arm, while, at the same moment, the elbow is lifted from the body ; 
second, in rotating the humerus upwards and outwards, employing the 
forearm as a lever ; and third, in reversing this last movement, that is, 
rotating the humerus downwards and inwards while at the same moment 
the elbow is carried again to the side. 3 

When the dislocation is into the axilla, this manoeuvre will generally 
succeed; but if the head of the humerus has slipped forwards, even only 
sufficient to engage itself slightly under the tendons of the coraco- 
brachialis and biceps, the outward rotation of the humerus will inevitably 
thrust the head further forwards, and fasten it more certainly underneath 
these tendons ; while the rotation of the humerus in the opposite direction 
will alone often be sufficient to carry the head directly into the socket. 

Mr. John lleynders, instrument-maker of this city, has recently shown 
me a cone made of ash-splittings, braided, and which is large enough to 
embrace and fasten itself to the forearm, for the purpose of extension 
(Fig. 271). He informs me that the apparatus was imported from Ger- 
many. It is the same as that described by me many years since as the 
"Indian puzzle," and w T hich will be seen represented in the chapter on 
" Dislocations of the Fingers." 

1 Boston Med. and Surg. Journ., vol. xxxix. p. 215. i lb., vol. xxxv. p. 454. 

3 H. H. Smith, Gross's Surg., ed. of 1863, p. 152. 



DISLOCATION OF THE HUMERUS DOWNWARDS. 653 

Ancient Luxations. — Finally, I ought to speak somewhat more in 
detail of the manner of procedure and of the principles involved in the 
reduction of old dislocations, or of dislocations requiring the interposition 
of mechanical appliances ; especially with a view to the more complete 
exposition of my own practice in these cases. 

Fig. 271. 




Indian pnzzle, employed to make extension in dislocations of the shoulder. 

If the dislocation is recent, but reduction is found impossible without 
the aid of mechanical apparatus, the difficulty will be understood to con- 
sist mainly, if not altogether, in the resistance offered by the muscles. 
If, in a few exceptional cases, the capsule, or an untorn tendon, or the 
margin of the glenoid fossa, present themselves as obstacles, they must 
still be considered as unusual and extraordinary impediments, the exist- 
ence of which may be regarded rather as possible than probable. 

Almost our sole purpose, then, it will be understood, in all recent 
cases requiring mechanical appliances, and in some ancient cases, is to 
overcome the contraction of the muscles. 

We prefer always to place the patient upon a mattress laid upon the 
floor ; two silk handkerchiefs, or two pieces of a cotton roller, are then 
laid along the radial and ulnar sides of the humerus, and over the middle 
of these, immediately above the condyles, a wetted roller is applied, its 
end being made fast with a needle and thread rather than with a pin. 
The upper ends of the longitudinal strips, or of the handkerchiefs, are 
now turned down and tied to the opposite ends, thus converting them 
both into lateral loops. For the purpose of making counter-extension, a 
sheet is passed around the body under the axilla, and made fast to a 
staple ; while an intelligent assistant is to manage the scapula with his 
naked hands, either by pulling with his fingers placed under the process, 
or by pushing with the palm of his hand and ball of his thumb. The 
pulleys, secured to a staple exactly opposite to that which holds the 
counter-extending band, are made ready, but not for the present attached 
to the arm. 

As soon as the patient is placed completely under the influence of an 
anaesthetic, the operator is ready to proceed with the reduction. It is 
my maxim never to attempt to accomplish by complicated and violent 
measures what may be done as well by more simple and gentle means. 
I think it proper, therefore, to make several attempts at reduction by 
manipulation alone, aided now by the anaesthetic, the extending and 
counter-extending bands, etc., before resorting to the pulleys. Seating 
himself upon the mattress, his boots being removed, the surgeon should 
bend the forearm to a right angle with the arm, and planting one heel 
in the axilla, with one hand he should seize upon the loops at the elbow, 



654 DISLOCATIONS OF THE SHOULDER. 

and with the other steady the hand and forearm of the patient, while he 
proceeds to make firm traction for a few seconds in the line of the body, 
or only a little out from this line. Failing in this, he may direct the 
assistant to seize upon the scapula, and make counter-extension ; still 
not succeeding, he may change his foot from the axilla to the acromion 
process, and pull directly outwards at a right angle with the body, or he 
may swing himself gradually around until he comes to be above the head 
of the patient, and the foot presses firmly upon the top of the scapula; 
now descending again in the same direction, he will very probably find 
the limb reduced, or capable of being reduced easily, by operating upon 
it as a lever by laying it across the body while at the same moment it is 
rotated slightly inwards. 

If still the reduction is not accomplished, the pulleys must at once be 
put in requisition. The sheet, passed around the chest and fastened to a 
staple, is only a means of supporting the body and rendering it more 
steady ; as a means of counter-extension its value is inconsiderable. To 
make fast the scapula, we must still rely mainly upon the naked hands 
of strong men, or upon a strap drawn firmly across the process and held 
in place by an assistant. 

Whenever we employ extension without the aid of anaesthetics, as 
sometimes we are compelled to do, it must be constantly borne in mind 
that it is proposed to conquer the muscles by fatiguing them, and that 
this cannot be done by a force suddenly applied, however great it may 
be, but only by gentle, steady, and long-continued extension. The 
muscles, when attacked openly and vigorously, resist, and will suffer 
laceration rather than yield, while, on the other hand, an insidious but 
persevering approach seldom fails to end in their defeat. The same is 
true, but in a much less degree, when the patient is insensible from 
anaesthesia. 

The forearm is again flexed, and the arm carried out to a right angle 
with the body, the pulleys secured to the loops, and the assistant takes 
hold upon the process, while the surgeon draws gently upon the rope 
attached to the pulleys ; as soon as everything is moderately tense, he 
is to desist for a few moments. Again the rope is drawn upon gently, 
and again the progress of the extension is suspended. In this way the 
operator is to proceed during half an hour, or two hours, as the nature 
of the case may demand; occasionally rotating the humerus, and occa- 
sionally lifting its head toward the socket. Meanwhile, it is understood 
that the principal counter-extension is made by the assistants, who must 
relieve each other, at the acromion process. The sheet in the axilla, or 
rather against the side of the chest, has some value in this respect when 
the arm is at a right angle with the body, but in itself it cannot control 
the scapula, only as it holds the body to which the scapula is attached. 
Much, therefore, as we may regret the inconvenience of making counter- 
extension by hands alone, experience and anatomy alike must teach that 
here it is the only mode. If these dislocations are reduced often by 
other methods, as no doubt they are, then it is only an evidence that in 
these examples little or no counter- extension was necessary. 

Sometimes the dislocation is not reduced when the extension is given 
up, but if then a resort is promptly made to some one of the simple 



DISLOCATION OF THE HUMERUS DOWNWARDS. 655 

methods already described, while the muscles are still exhausted, it very 
often happens that the reduction is easily accomplished. 

It will be prudent in all cases, in order to prevent a reluxation, whether 
the dislocation is recent or ancient, as soon as its reduction is effected, to 
place the arm in a sling and secure the elbow to the side by a few turns 
of a roller. I do not think the axillary pad necessary, and I am afraid 
it has sometimes done as much mischief as the dislocation itself. 

The following example will illustrate the variety of expedients to which 
we are obliged sometimes to resort before our efforts prove successful: — 

Thomas Leeding, of Niagara Co., N. Y., aet. 52, a laborer, and a 
muscular man, dislocated his right arm into the axilla, by jumping from 
the cars when they were in full motion. The blow was received upon 
the shoulder. An intelligent country surgeon, assisted by several other 
persons, attempted reduction within an hour after the accident, but failed, 
and as the patient had some distance to travel, he was not brought under 
my notice until eighteen hours had elapsed. We first administered 
chloroform, and then, while an assistant held firmly upon the acromion 
process, I pulled in the line of the body, then outwards, and finally up- 
wards, but to no purpose. Having then applied Jarvis's " adjuster," 
and after the arm had been kept extended at a right angle with the body 
fifteen minutes, we removed the apparatus, and found the bone in its 
place. 

John Harrington, set. 50, a very large and powerful man, fell, while 
intoxicated, and dislocated his left humerus into the axilla. No surgeon 
was called until the tenth day, when he first consulted Dr. Dudley, who 
at once brought him to me. Without delay w T e applied the pulleys, and 
placing the arm at a right angle with the body, we made extension fifteen 
minutes ; occasionally also rotating the arm. We then removed the 
pulleys, and while an assistant held upon the acromion process, with my 
heel in the axilla, I made extension in the line of the axis of the body, 
then outwards, and finally upwards with my foot upon the top of the 
scapula. I next seated my patient in a chair, and drew his arm and 
axilla forcibly over my knee. The bone was not yet reduced ; I there- 
fore bled him twenty-four ounces, or until partial syncope was induced, 
and proceeded to repeat most of these processes, but with no better re- 
sult. At this moment I determined to use sulphuric ether, w T hich had 
just been introduced as an anaesthetic, and while he was completely under 
its influence the pulleys were again applied, and the extension continued 
for some time, and until the rope broke. He was then again placed in 
a chair, and the axilla brought over my knee, when in a moment the 
reduction was accomplished. 

Julia McKnight, set. 39, admitted to ward 28, Bellevue, in November, 
1866, with a dislocation of the humerus into the axilla, which had ex- 
isted seven weeks and one day. The deltoid was much wasted and the 
hand somewhat numb. Before the class of medical students, the patient 
being under the influence of ether, the reduction was effected ; but not 
until various methods of manipulation and extension had been tried and 
had failed. Having finally carried the arm directly upwards — La Mothe's 
method — and in this position employed extension, the arm was again 
brought down, and with moderate manipulation the reduction was effected. 



656 DISLOCATIONS OF THE SHOULDER. 

The return of the bone was sudden, and was accompanied with a slight 
grating sensation ; it was observed also, that a hard bony projection was 
left in the axilla, Avhich was no doubt the margin of a new socket. The 
head of the humerus could be plainly seen and felt in its socket, render- 
ing it certain that we had not broken the surgical neck of the humerus. 

John Bowles, of Buffalo, aged 45 years, an Irish laborer, tolerably 
muscular, but spare. Bowles fell down a flight of stairs, and dislocated 
his left humerus into the axilla. The shoulder became much swollen, 
and was very painful, but he did not suspect a dislocation and did not 
consult a surgeon. Eight weeks after the accident he applied to me. 
There were present the usual signs of this dislocation, but the arm was 
by careful measurement one inch and a half longer than the other. 

The reduction was accomplished on the same day, in the presence of 
Drs. Lee, Webster, Coventry, Ford, and Jewett. The time occupied in 
the reduction was about two hours. An attempt was first made with 
the heel in the axilla and with violent rotation and extension. The same 
plan was repeated with the aid of ether, which was administered freely. 
Jarvis's adjuster was now applied, with no result, except that, either in 
consequence of the force employed by the adjuster, or in consequence of 
the free use of ether, or of both, he became convulsed violently, which 
was accompanied by frothing at the mouth and other grave symptoms. 
The adjuster was removed, and the exhibition of ether discontinued. As 
soon as the convulsions ceased, and before consciousness had returned, 
extension, rotation, etc., were again made by hands. Finally, after all 
extension was relinquished, placing my knee in the axilla, I reduced the 
bone by a very slight rotary action upon the arm ; the bone was at once 
plainly in its socket, but the unusual length of the limb continued, being 
one inch and a half longer, though it could be shortened to the same 
length as the other by lifting the elbow. A pad was placed in the ax- 
illa, and the arm secured with a sling and roller. The next day the arm 
remained in place, but it was now only one inch longer than the other. 
At the end of a fortnight it was only three-quarters of an inch longer, 
and could be reduced to the same length by lifting ; the pain and swell- 
ing about the shoulder, which never were great, were subsiding, and the 
patient was dismissed. 

However skilfully our efforts may be directed, they will be found 
occasionally to fail ; either owing to adhesions which have taken place 
between the head of the bone, or rather its capsule, and the adjacent 
tendons, muscles, etc., to some extraordinary position of the head and 
neck of the bone in its relation to ligamentous or tendinous structures, 
to a filling up of the glenoid fossa, or to some other cause not fully ex- 
plained. Such failures have happened not only in the hands of ignorant 
and unskilful surgeons, destitute of appliances, but also in the hands of 
those who are the most expert, and who are the most completely pro- 
vided with all the necessary apparatus. Indeed, if the truth were known, 
it would probably be found that the number of failures after the sixth or 
eighth week has been greater than the successes. The records of sur- 
gery, however, furnish a great many examples of ancient dislocations of 
the humerus reduced after periods ranging from one month to six, or 
even longer. Dieffenbach has been able to accomplish the reduction of 



DISLOCATION OF THE HUMERUS DOWNWARDS. 657 

a forward dislocation after two years, but not until he had cut the ten- 
dons of the pectoralis major, latissimus dorsi, teres major, and teres 
minor, and had divided the ligaments surrounding the new joint. 1 

In a case in which the head of the humerus, long dislocated, pressed 
upon the brachial plexus, causing great suffering, Dr. Edward Warren, 
of Baltimore, practised resection, in 1869, giving immediate and perma- 
nent relief. 2 

Dr. Thomas Annandale, Surgeon to the Edinburgh Infirmary, in the 
case of a woman 62 years old, with a subclavicular dislocation of six 
weeks' standing, having failed to reduce the bone, and the patient suffer- 
ing great pain on account of the pressure upon the axillary nerves, cut 
down upon the head of the humerus, along the inner border of the del- 
toid, and after separating the axillary artery, which was adherent to the 
bone, and having sawn through the surgical neck of the humerus, he re- 
moved the head in fragments and with great difficulty, inasmuch as it 
was firmly bound to the ribs by fibrous and bony tissues. In the course 
of this procedure he wounded the circumflex artery so near to its origin, 
that he was obliged to tie the subclavian above and below the origin of 
the circumflex. The operation was performed February 16, 1875. On 
the 18th the hand and forearm became gangrenous, and on the 19th she 
died. 3 

It would be unjust to the young surgeon not to call especial attention 
to the numerous examples of serious and even fatal accidents which have 
followed upon the attempts to reduce ancient luxations at this joint. 

Rupture of the- Axillary Artery. — The late George C. Blackman, of 
Cincinnati, a distinguished surgeon, having met with one of these unfor- 
tunate accidents in his own practice, has had the candor to make a pub- 
lic statement of the case and of the circumstances which attended it. In 
a letter to the editor of the Western Lancet, published in the November 
number for 1856, he writes as follows : — 

" About the 10th ult., aided by yourself, I succeeded in reducing by 
manipulation, without the pulleys, a dislocation into the axilla, of eighty 
days' standing. The reduction was accomplished in a very few minutes, 
under the influence of chloroform and ether, and the next morning the 
patient left for the country, in a comfortable condition. Since that I 
have received no tidings from. him. Encouraged by the result in this 
case, another patient, himself a physician, a tall, athletic man, and about 
fifty years of age, decided to submit to the same manipulation, although 
his arm had been dislocated for about sixteen weeks. The dislocation 
was downwards and inwards, and about the tenth week an unsuccessful 
attempt, by another surgeon, had been made with the pulleys, to which 
the force of six men was applied for two and a half hours. The pa- 
tient being under the influence of chloroform and ether, aided by your- 
self, Drs. Eries, Cary, Graham, and Kauffman,I commenced by manipu- 
lations, adducting, rotating, abducting, and elevating the arm. These 
efforts had been made for about ten minutes, and the least possible vio- 

1 Dieffenbach, Bost. Med. and Surg. Journ., vol. xxii. p. 382, fromMedicin. Zeitung. 

2 Warren, Gross's Lecture, Amer. Journ. Med. Sci., April, 1876, p. 452 ; also, Bait. 
Med. Journ.. Sept. 1871, p. 532. 

3 Annandale, Med. Times and Gaz., May 9 9, 1875, p. 576. 



658 DISLOCATIONS OF THE SHOULDER. 

lence employed, when a tumefaction appeared in the pectoral region, 
which, in a few minutes, attained a considerable size. Supposing that 
the axillary artery was ruptured, as no pulse could be felt at the wrist, 
a ligature was immediately applied to the vessel at the upper part of its 
course. The operation was performed about 10 o'clock A.M., and com- 
pression of the pectoral region made by means of a sponge and broad 
roller. On removing this the next morning, the tumefaction had nearly 
disappeared. The patient continued comfortable, and about nine days 
after the application of the ligature I was compelled to leave the city on 
a professional visit to Indiana. I left on Friday afternoon and returned 
on Monday morning, at which time I learned that my patient had died 
on Sunday morning, from hemorrhage at the seat of ligature." 

The following is a resume of similar accidents which have from time 
to time occurred in the practice of other surgeons. 

Desault twice observed, after attempts to reduce old luxations of the 
shoulder, " tumeurs aerie?ine8." It is quite probable, however, that in 
each case the tumor was caused by the rupture of a bloodvessel, and 
probably an artery. 1 

Pelletan, also, attempting to reduce a luxation of four months' stand- 
ing, thought he produced a tumeur aerienne, but it being opened the 
patient bled to death. 2 

Malgaigne, attempting to reduce a dislocation of sixty-eight days' 
standing, was surprised by a sudden tumefaction in the axilla, and on 
the shoulder, which caused so much alarm as to induce him to discon- 
tinue his efforts. Ice was applied, and the hemorrhage, which he thought 
came from muscular branches, was arrested. 3 Verdoc saw the axillary 
artery ruptured in the same manner, in consequence of which the pa- 
tient died. 4 J. L. Petit, Dupuytren, and Nelaton met with similar 
cases. C. Bell reports an example of rupture of the artery with exten- 
sive laceration of the muscles, and which demanded immediate amputa- 
tion. Delpech ruptured the artery, and his patient died immediately. 5 
Flaubert was more fortunate, the effused blood being absorbed after a 
few days. 6 John C. Warren, of Boston, tied the subclavian artery to 
arrest the progress of an enormous aneurismal tumor in the axilla, caused 
by the reduction of a recent dislocation. 7 Gibson, of Philadelphia, lost 
two patients from rupture of the artery in attempting to reduce old lux- 
ations of the humerus, 8 and he relates another fatal case occurring in the 
practice of David, of Rouen. Leudet, of Rouen, lost a patient in this 
way in 1825. In this latter case, and in both the cases occurring in the 
practice of Gibson, there was a fracture, also, of the lower margin of the 
glenoid cavity. Callender ruptured the artery in an attempt to reduce 
a dislocation at six weeks. 9 Mr. Lister met with the same accident. 10 

1 Desault, Journ. de Chir., t. iv. p. 301. 

2 Pelletan, Chir. Clin., t. ii. p. 951. 3 Malgaigne, Paris ed., 1855, p. 150. 

4 Verduc, Operat. de la Chir., 1693, t. i. p. 559. 

5 Malgaigne, op. cit., p. 152. • 

6 Memoires sur plusieurs cas de Luxationes, etc. Repertoire d'Anat. et de Phys., 
1827, Obs. 3. Four cases of injury to the Axillary or Brachial Vessels or Nerves. 

7 Warren, Amer. Journ. Med. Sci., vol. xi. N.'S. 1846. 

8 Gibson, Elements of Surg., vol. i. p. 824, 4th ed. 

9 St. Barthol. Hosp. Rep., 1866, vol. ii. p. 96. 
10 Med. Times and Gaz., Feb. 1, 1873. 



DISLOCATION" OF THE HUMERUS DOWNWARDS. 659 

Rupture of the Axillary Vein. — Froriep attempted the reduction of 
the shoulder in a woman, set. 36, the dislocation having existed twenty 
days. The axillary vein was torn entirely across, and death ensued in 
an hour and a half. 1 

Professor D. H. Agnew, of the University of Pennsylvania, ruptured 
the axillary vein while attempting to reduce a dislocation of six weeks. 
The woman, set. 60, had a subcoracoid dislocation, and while the arm was 
lifted and extension made according to La Mothe's method, the vein was 
ruptured, causing a very large tumor covering the entire breast. Com- 
presses and bandages were at once applied and continued for several 
weeks, the case resulting in a complete cure, but with the bone un- 
reduced. 2 

Rupture of Artery and Vein. — Platner mentions a case of rupture of 
both artery and vein, in which death ensued from subsequent rupture of 
the sac. 3 

Charles Bell reports a case in which the artery was ruptured, at the 
New Castle Infirmary, and the parts adjacent so much injured that 
immediate amputation became necessary. It seems quite probable 
therefore that the vein was also torn, but this is not stated. 4 

Dr. H. B. Sands, of New York, in attempting to reduce a downward 
dislocation of seven or eight weeks' standing, in a lady eighty-six years 
of age, found a tumor rapidly forming in the axilla, which soon attained 
the size of a child's head at full term; discoloration ensued, and the pulsa- 
tion of the brachial, ulnar, and radial arteries were lost. She was also 
greatly prostrated. It was evident that some vessel had given way, but 
inasmuch as she finally recovered without any surgical operation, it is 
scarcely probable that it was, as at first suspected, a rupture of the 
axillary artery. I ought to add that the patient was, at the time of 
attempted reduction, under the influence of ether, and that great care 
Avas said to have been exercised by Dr. Sands not to employ great force 
in the attempt. The reduction was not accomplished. 5 

Cerebral Congestion. — In a case reported by Lisfranc, death is as- 
cribed to cerebral congestion. 6 

Injury to Axillary Nerves. — Very many accidents of this kind have 
happened from time to time, some of which have been reported by Flau- 
bert, Malgaigne, Lenoir, Larrey, and others. 7 

Avulsion of the Arm. — Guerin tore the arm completely from the 
body, in an attempt to reduce a dislocation of three months' standing, in 
a woman 63 years of age. 8 

Inflammation, etc. — Mr. Hutchinson, of London, reported in 1866 
that inflammation, suppuration, and death had resulted from an attempt 
made to reduce an old dislocation of the humerus, under his own observa- 

1 Malgaigne, from Froriep. 

2 Agnew, Phila. Med. Times, Aug. 16, 1873. 

3 Malgaigne, Paris ed., 1855, vol. ii. p. 151. 

4 Willard, Summary of Cases, Phila. Med. Times, Aug. 16, 1873. 

5 Sands, Med. Graz., March 8, 1880. 

6 Malgaigne, Paris ed., 1855, vol. ii. p. 161. 

7 Malgaigne, Paris ed., 1855, vol. ii. p. 151. 

8 S. Cooper's First Lines, vol. ii. p. 466 ; Amer. Journ. Med. Sci., 1828, p. 136. 



660 DISLOCATIONS OF THE SHOULDER. 

tion. 1 A like result followed the reduction of a recent subclavicular 
dislocation, in the practice of Dr. Courtright, of Ohio. 2 

Fracture of the Humerus.— -In the following case an attempt to re- 
duce an ancient dislocation of the humerus occasioned a fracture of the 
surgical neck. 

Martha Hogan, get. 70, of Brooklyn, N. Y., was admitted into the 
Long Island College Hospital during the spring of 1860. The dislo- 
cation had existed six weeks, and was subcoracoid. On the day of 
admission an attempt was made to reduce it, both by Dr. Johnson and 
myself, without an anaesthetic, in which we both failed. I then gave 
her ether, and now discovered that she had a fracture of the second and 
third ribs on the same side. The fractures were ununited. While 
manipulating, pulling the arm gently and rotating, the surgical neck of 
the humerus gave way. She did not survive the injury many days, and 
the autopsy confirmed this diagnosis. 

In December, 1874, Dr. Stephen Smith, of Bellevue, met with the 
same accident in attempting to reduce a subglenoid dislocation of eight 
weeks' standing, before the class of medical students. The patient, a 
man aged about 40, was under the influence of ether. Manipulation and 
extension had been freely employed in various directions, but the frac- 
ture took place w T hen, at my suggestion, extension was for a moment 
relinquished, and while Dr. Smith was rotating the humerus with the 
elbow at a right angle with the body. 

In December, 1865, Rosanna Casey, set. 32, was admitted to Belle- 
vue with a subcoracoid dislocation of the left shoulder. The accident 
occurred six weeks before. On admission, one of the house surgeons 
attempted reduction, and, as I am informed, fractured the surgical neck 

of the humerus. After which, Dec. 9th, I attempted reduction before 

the class, the patient being under the influence of ether, but without 

success. Malgaigne has recorded four similar cases. 3 

Two cases are referred to in the Lancet, February 6, 1876 ; in one 

of which, however, a suspicion is expressed that the fracture occurred at 

the same time as the dislocation. In my opinion the fracture was 

caused by the attempt at reduction. 4 

Summary of the Graver Accidents. — Rupture of an artery, eighteen 

cases ; most of which were known to be ruptures of the axillary artery. 

Callender, Lister, and Blackman tied the axillary, and the patients all 

died. The subclavian was tied by Warren successfully. Gibson also 

tied the subclavian, but his patient died. Nelaton did the same, and the 

result is not stated. 

Rupture of vein alone, two cases. Froriep's patient died ; Agnew's 

patient was saved. 

Rupture of artery and vein, probably two cases. Platner's patient 

died. In Bell's case the result is not stated, except that amputation was 

practised. 

1 Hutchinson, Lond. Hosp. Reports, vol. ii. (Cincinnati Journ. Med., Aug. 1866, p. 
361). 

2 Courtright, Cincinnati Lancet and Observer, Jan. 1877. 

3 Malgaigne, Paris ed., 1855, vol. ii. p. 143. 

4 Med. Review and Library, March, 1876, from the Lancet. 



DISLOCATION WITH FRACTURE. 661 

Rupture of unknown vessel, one case. No operation. Recovery. 

Avulsion of arm, one case. Patient died. 

Of the whole number, twenty-four, fifteen terminated fatally, in three 
the results are uncertain, and seven recovered. 

Of fractures of the neck of the humerus I have reported three cases, 
and I have drawn from other sources six cases, making in all nine. 
My own patient died, but probably not in consequence of any injury 
suffered in the attempt at reduction. 

Norris has reported three cases of ancient dislocation into the axilla, 
treated at the Pennsylvania Hospital : one, of four weeks' standing, was 
reduced in thirty seconds by the aid of pulleys ; the second, which had 
existed seven weeks, was reduced by the same means in about one hour ; 
and the third, dislocated ten weeks, was left unreduced after extension 
and counter-extension had been made for an hour. In the second case, 
however, suppuration occurred in or about the joint, and, on the tenth 
day, the abscess was opened, giving exit to a large amount of pus. He 
left the hospital with the parts about the shoulder still much hardened 
and stiff. 1 

Dislocation, with Fracture of the Humerus near its Upper End. — 
We have thus far omitted to speak of the treatment of dislocations of the 
humerus accompanied with fracture near its upper end. The older 
writers, almost without an exception, agree in declaring the reduction of 
these dislocations impossible, until the fracture had united. And, so late 
as the year 1828, we have the report of a case treated in this manner by 
a surgeon in Massachusetts. Dr. Warren, of Boston, himself reduced 
the dislocation at the end of four weeks, when the fracture was found to 
have united. 2 But since the introduction of anaesthetics immediate at- 
tempts at reduction have more often proved successful ; and in no case 
can the surgeon excuse himself for having omitted to make the effort. 

Richet reports an example of this kind in a man sixty-eight years of 
age, in whom the dislocation was complicated with a fracture of the neck 
of the humerus. The attempt was not made until the fourth day, when 
it proved successful without extension. The fracture was afterwards 
adjusted and consolidated, so that he recovered the complete use of his 
arm. 3 

At a meeting of the New York Academy of Medicine in May, 1855, 
Dr. Watson reported a case of fracture of the humerus near its head, 
complicated with a dislocation into the axilla. The patient was a robust 
man, past the middle age, and had received the injury by a blow on 
the shoulder from a steam-engine. He was very much prostrated at the 
time of being admitted into the hospital, and the examination was not 
made until the following morning. The arm was then found lying close 
to the side, but in other respects it presented the usual signs of a dislo- 
cation. Ether was immediately administered ; and w r hile extension and 
counter-extension were applied, and a sweeping motion given to the arm, 

1 Norris, Amer. Journ. Med. Sci., vol. xxxi. p. 24. 

2 Boston Med. and Surg. Journ., No. 1, 1828 ; also, Arner. Journ. Med. Sci., vol. ii. 
p. 233. 

3 Richet, Amer. Journ. Med. Sci., vol. xii., new ser., p. 293, from Bulletin de 
Therap. 



662 DISLOCATIONS OF THE SHOULDER. 

drawing it from the body, firm pressure with the fingers was made in the 
axilla, forcing the head toward the socket, and the bone slipped into its 
position. 1 

In the Transactions of the American Medical Association, I have re- 
ported a case of supposed dislocation, accompanied with a fracture which 
I succeeded in reducing on the eighth day. 2 

I have, however, twice failed in attempts to reduce similar dislocations. 
The first patient, John Riley, get. 49, was admitted to Bellevue Hospital, 
March 29, 1864, having received the injury two days before. The dis- 
location was subcoracoid, and the humerus was broken at its surgical 
neck. Having placed him under the influence of ether, assisted by Dr. 
Stephen Smith and several other surgeons of the hospital, I attempted to 
reduce the dislocated bone, but after a trial, prolonged through one hour 
or more, the effort was abandoned. 

The second case was in a man aged about 40 years, who was admitted 
to Bellevue Hospital in July, 1864, with a dislocation of the head of the 
humerus forwards, and a fracture of the surgical neck, of four weeks' 
standing. A surgeon had attempted reduction immediately after the 
receipt of the injury, but had failed. We found the fracture still un- 
united, and placing him under the influence of ether, we tried faithfully, 
by pushing and pulling, and by various other manoeuvres, to reduce the 
dislocation, but without success. 

The fractures united in both cases promptly, and attempts were subse- 
quently made to reduce the dislocation, but to no purpose. 

Examples have been recorded, however, by surgeons in which the reduc- 
tion has been accomplished immediately, and without much difficulty, by 
simple pressure upon the head of the bone, while the patient was under the 
influence of an anaesthetic, and without the aid of extension ; indeed, 
it is quite doubtful whether extension in these cases is of any service. 
I have already said that I have once succeeded in replacing the head in 
its socket after the lapse of eight days. But, if the surgeon were to 
fail by pressure alone, it would be proper to employ extension and 
manipulation. 3 In the event of a failure by these means, the case ought 
to be treated as a fracture, and the earliest period after the union of 
the fragments should be seized upon to accomplish the reduction of the 
dislocation. The occasional success of the older surgeons by this method 
is sufficient to warrant the attempt. 

Compound dislocations of this joint will be discussed in a separate 
chapter devoted to the general consideration of compound dislocations of 
all the joints connected with the long bones. 



§ 2. Dislocation of. the Humerus Forwards. (Subcoracoid and Subclavicular.) 

Causes. — The causes of this dislocation are the same with those w T hich 
produce dislocation downwards into the axilla, except that it is more 

1 Watson, Amer. Journ. Med. Sci., vol. xvi., new ser., p. 383. 

2 Op. eit., vol. ix. p. 93. 

3 Hartshorne, Case reduced by Manipulation, Amer. Journ. Med. Sci., Jan. 1855, 
pp. 273-4, from Med. Examiner. 



DISLOCATION OF THE HUMERUS FORWARDS. 663 

likely to occur in a fall upon the elbow or upon the hand when the line 
of the axis of the arm and forearm is thrown behind the body. Where 
my records have stated the cause it has been ascribed to a direct blow 
upon the shoulder sixteen times, and to a fall upon the hand or elbow 
only twice. If it is the result of a direct blow, the impulse has usually 
been received rather upon the back than upon the outer side of the head 
of the humerus ; or the upper end of the bone, having been originally 
thrown directly downwards upon the inferior edge of the scapula, may 
have been made to assume the position forwards, beneath the pectoral 
muscle, in consequence of the peculiar action of the muscles, or of the 
position pf the arm in an attempt to rise. By this latter mode of expla- 
nation the dislocation forwards is consecutive only upon a dislocation 
downwards. 

In several instances which have come under my notice the dislocation 
has been due to muscular action alone. In one example the dislocation 
occurred frequently in consequence of epileptic convulsions. This was 
in the person of a lad, set. 18, of a slender frame and feeble muscles. 
When the dislocation had taken place, he was frequently able to reduce 
it himself ; sometimes he was obliged to call upon a surgeon, and at 
other times he left it out a day or two, or until it became reduced spon- 
taneously. This spontaneous reduction generally took place at night, 
during sleep. At the time he called upon me the bone had been out 
two days, and he could not reduce it. I administered chloroform, and 
then made repeated and prolonged efforts at reduction, adopting all the 
usual modes of manipulation, but without resorting to mechanical appli- 
ances. The father now refused to allow me to proceed, and he was 
taken home with the bone unreduced. The following day he called at 
my office, to say that during the night, while asleep, and, he thinks, 
while turning over in bed, the bone suddenly resumed its place. 

Drs. Edward L. Pardee and Glover C. Arnold, of this city, have re- 
cently met with a case of simultaneous dislocation of both shoulders, in 
a man set. 38, caused by a fall from a carriage, his arms being extended 
in front of him, and the force of the concussion being received upon his 
hands. Both of the dislocations were subcoracoid ; and they were easily 
reduced by Dr. Arnold. 

Surgical writers occasionally refer to similar examples, but the num- 
ber of cases of double dislocation on record is small. Most of those 
recorded have happened when the arms were extended in front of the 
body, as in Dr. Pardee's case just cited ; and the dislocations were gene- 
rally subcoracoid. 

Pathology. — Omitting for the present to speak of partial luxations, 
the existence of which, as a form of traumatic dislocation, we are pre- 
pared to question, we shall proceed at once to describe the anatomical 
relations and the various lesions which generally accompany a complete 
luxation forwards. 

Of these we shall observe two principal varieties, differing mainly in 
the degree or extent of the displacement. 

Thus we may find the head of the humerus resting beneath the cora- 
coid process (subcoracoid), having the conjoined tendon of the short head 
of the biceps and of the coraco-brachialis lying upon its anterior surface, 



664 



DISLOCATIONS OF THE SHOULDER. 



while its posterior and outer surface rests upon the venter of the scapula 
in front of the glenoid fossa ; in which position it has usually thrust up, 
to a greater or less extent, the belly of the subscapular muscle. 

Sir Astley Cooper, Fergusson, and others, when mentioning this form 
of dislocation, call it a "dislocation into the axilla ;" by Boyer it is called 
a " primary luxation forwards." Dr. Wood, of New York, has reported 
an example, accompanied with a fracture of the neck of the humerus, 
which he has named " dislocation under the subscapulars muscle." The 
drawing which accompanied the report, made from the autopsy, suffi- 
ciently shows that it was a dislocation of the same character as that which 
we are now describing. 1 Dr. Parker has called attention to a similar case, 
an account of which was first given in Reese's edition of Cooper's Sur- 
gical Dictionary . The head of the humerus reposed in the "subscapular 
fossa." 2 By Malgaigne, Vidal (de Cassis), and others, this is called a 
subcoracoid dislocation, a term which, as being more distinctive and ap- 
priate than either of the others, I shall choose to adopt. 



Fig. 272. 



Fig. 273. 





Suljcoracoid dislocation. 



Subclavicular dislocation. 



In the second variety, the head, having escaped from underneath the 
coracoid process, is made to approach nearer to the sternum, so as to ap- 
ply itself more or less closely to the inferior edge of the clavicle (sub- 
clavicular). In which case the head and neck will be placed behind the 
pectoralis minor, and also behind the short head of the biceps and coraco- 
brachial ; or between these several muscles on the one hand, and the 
serratus magnus, covering the second and third ribs, on the other hand. 

Upon the appearances which accompany this more advanced form of 
dislocation writers have generally based their descriptions, diagnosis, 
treatment, etc., of forward luxations. 

In either form of the accident, the deltoid, with the supra- and infra- 
spinatus, is greatly stretched, and the two latter sometimes torn ; the 



1 Wood, New York Journ. of Med., May, 1850, p. 282. 

2 Parker, New York Journ. of Med., March, 1852, p. 187. 



DISLOCATION OF THE HUMERUS FORWARDS. bbo 

subscapularis is displaced upwards and backwards, while its tendon is in 
some instances completely wrenched from the head of the humerus. Mr. 
Erichsen has seen the lesser tubercle itself completely broken off in two 
examples of this accident which he has been permitted to examine after 
death. 1 Occasionally the axillary nerves are carried forwards with the 
head of the bone : and in this case the pain produced by their being thus 
pressed upon is even greater than in dislocations into the axilla. 

In this accident, as in dislocation downwards, the long head of the 
biceps is sometimes broken : the circumflex nerve may be contused or 
ruptured, and the capsule is generally torn very extensively. 

Symptoms. — If the dislocation is subclavicular (Fig. 273), a depres- 
sion exists under the outer end of the acromion process, extending also 
..underneath its posterior margin: the elbow hangs away from the body, 
and a little backwards : the axis of the limb is much changed, being 
thrown inwards in the direction of the middle of the clavicle, the whole 
body inclining moderately to the same side: there is also more or less 
inability to move the arm, especially in a direction forwards or outwards : 
a fulness is seen underneath the clavicle, and to the sternal side of the 
coracoid process, occasioned by the head of the humerus, the head mov- 
ing with the shaft ; the arm is shortened. To these we may add the 
common sign of all dislocations of the humerus, mentioned by Dugas, 
viz.. the impossibility of placing the hand upon the opposite shoulder 
while at the same moment the elbow is made to touch the front of the 
chest. 

If the dislocation is forwards, but subcoracoid, the head of the bone 
will be found below this process and deep in the anterior margin of the 
axillary fossa. It cannot, therefore, be so distinctly felt; but the other 
signs are the same as in the dislocation forwards under the clavicle, ex- 
cept that the arm is shorter, not longer. 

Prognosis. — While on the one hand experience has shown that the 
axillary nerves and artery are less liable to suffer serious and permanent 
injury than in dislocation downwards (subglenoid), and that the capsule, 
with the tendinous and muscular tissues about the joint, are no more 
liable to laceration — on the other hand, the difficulty of reduction has 
been often increased, and consequently a large number of examples, in 
proportion to the actual number which occur, have been left unreduced. 

Dr. Norris relates a case which the surgeon who was first called sup- 
posed to be a mere contusion, but which, on being admitted to the Penn- 
sylvania Hospital, three months after the accident, was found to be a 
dislocation forwards under the clavicle. The arm was almost useless. 
Dr. Norris made extension and counter-extension with compound pulleys 
nearly an hour, but to no purpose : and finally, at the request of the 
patient, the attempt was given over. 2 

Treatment. — The same rules of treatment which we have established 
in relation to dislocations into the axilla (subglenoid) will be found to be 
applicable to this dislocation ; with the exception that the extension will 
have to be made generally at first somewhat in a line backwards from the 

1 Erichsen, Science and Art of Surgery, 2d Arner. ed., p. 250. 

2 Xorris. Anier. Journ. Med. Sci., vol. xxv. p. 279. 
43 



666 



DISLOCATIONS OF THE SHOULDER. 



body, and that our efforts will frequently have to be continued with more 
perseverance, although with less fear of injury, in consequence of supposed 
adhesions between the artery and the adjacent tissues. The extension also 
must always be made downwards and outwards, if the dislocation is sub- 
clavicular, until the head of the bone has escaped from beneath the 
coracoid process ; we may then pull directly outwards or even upwards, 
while at the same moment pressure is made with the hand upon the head 
of the bone in the direction of the socket, and the arm is rotated inwards. 

Fig. 274. 




Subcoracoid dislocation. 



If the dislocation is subcoracoid, our modes of procedure need scarcely 
vary in any respect from those which we have recommended for disloca- 
tions into the axilla. 

The plan adopted in the following case has been found sufficient in 
several examples of subcoracoid dislocation: — 

Mr. McA., of Buffalo, get. 73, moderately muscular, fell through a 
trap-door, striking upon his right elbow, and dislocating the humerus 
forwards. Within two hours after the accident, I found the head of the 
bone resting under the coracoid process, where it could be distinctly felt 
and seen. There was a marked depression under the acromion process, 
and the arm was carried out from the body and slightly back. He had 
not suffered much pain. The patient was seated in a chair, and while 
Dr. Lemon, who was at that time my pupil, supported the acromion pro- 
cess, I pushed the head of the humerus outwards toward the socket with 
my left hand, while with my right I pulled gently upon the arm in the 
direction of the axis of the body. After about twenty seconds it slid 
suddenly into its place with an audible snap. 



DISLOCATION OF THE HUMERUS FORWARDS. 667 

Simple manipulation alone will also be found sufficient in many cases 
of subclavicular dislocation. 

A German, Simeon Grennas, set. 21, fell upon an icy sidewalk, and 
dislocated his right humerus under the clavicle. We found him about 
an hour after the accident sitting with his head inclined to his right side, 
and supporting his elbow with his left hand. A marked depression ex- 
isted under the outer end of the acromion process, and instead of the 
usual fulness there was a flatness under the process behind. The elbow 
was carried out from the body, and very slightly backwards. While Dr. 
Boardman supported the acromion process I lifted the elbow from the 
side, carrying it first upwards and backwards, and then forwards, making 
thus a short detour with the arm, and when the manoeuvre was nearly 
completed the bone slid into its socket with a slight snap. No extension 
was used, and no more force employed than was sufficient to lift and 
rotate the arm. He was not at the time of the reduction, faint, nor were 
his muscles relaxed from any other cause. 

More than once I have accomplished the reduction by extension made 
directly upwards, as in the following example. 

A gentleman, forty-five years of age, had his left shoulder dislocated 
forwards under the clavicle in a railroad collision, on the 8th of October, 
1858. A young surgeon had been making extension in various ways for 
half an hour, when, by placing my foot upon the top of the scapula and 
drawing the arm directly upwards, I accomplished the reduction imme- 
diately and without much effort. Six months after the accident, I found 
the deltoid muscle considerably wasted, and he was still unable to raise 
his arm to a right angle with the body. 

I have in this way also reduced a dislocation which had existed seven- 
teen days, the nature of the accident having been misunderstood by the 
attending surgeon. The man was twenty-three years old, and quite mus- 
cular. The dislocation had been produced by a severe blow received 
directly upon the shoulder, and the arm was still considerably swollen 
and very tender. The reduction was accomplished in a few seconds while 
the patient was under the influence of chloroform, but by my hands alone, 
aided only by the pressure of the foot upon the top of the scapula. The 
method adopted successfully in both of the preceding cases, namely, pull- 
ing directly upwards, ought generally to be considered a last resort, inas- 
much as it especially exposes the axillary artery, vein, and nerves to 
injury. 

In December, 1857, Dr. White, of Buffalo, and myself, reduced a sub- 
clavicular dislocation of the right shoulder, which had existed sixty days, 
in a man sixty-eight years of age. The surgeon who first saw the man 
thought it was only a sprain or a severe bruise. When he came to 
Buffalo, the whole limb was enormously swollen, and neither Dr. White 
nor myself had much expectation of accomplishing a reduction without 
a resort to pulleys and anaesthetics . He was, however, placed upon the 
floor, and after extension made for about half an hour, during which time 
we had pulled the arm in various directions, upwards, outwards, and 
downwards, I at last succeeded while my heel was placed in the axilla, 
and while the limb was undergoino; a slight rotation. No anaesthetic 
was employed. 



DISLOCATIONS OF THE SHOULDER. 

Dr. M. C. Cuykendall, of Bucyrus, Ohio, informs me that he has 
recently reduced a subclavicular dislocation on the sixty-fourth day, in a 
man 62 years old, by the following method : "Asa last resort I secured 
the pulleys to the arm above the elbow, making the counter-extension 
with Skey's knob' in the axilla, flexed the arm and made extension down- 
wards and forwards ; and when well extended I moved his body under 
the pulley ropes, so as to bring the arm forcibly across the breast; then, 
keeping up the extension, I had Dr. Richey place his knee upon the top 
of the scapula, and lock his fingers around the elbow, while I placed my 
knee against the elbow and locked my fingers around the top of the 
scapula, and directing the extension removed, we forced the bone upwards 
and outwards to its sockets;" adhesions were felt to give way, and the 
restoration of the bone was found to be complete. 

It will be understood that this method did not succeed until after 
repeated and long-continued eiforts had been made by other methods, 
such as pulling down, pulling out, and pulling directly up. Dr. Cuy- 
kendall informs me that this is the second time he has succeeded in 
"completing" the reduction of old dislocations of the shoulder by this 
manoeuvre. 

These several cases are mentioned that the surgeon may understand 
how impossible it is always to establish absolute and invariable rules of 
procedure which shall be applicable to every accident of this character. 
The method which will succeed readily in one case may fail completely 
in another, although belonging to the same class, and not apparently 
differing in its anatomical relations. Before relinquishing the attempt, 
we ought to have put into requisition all the expedients which the ex- 
perience of other surgeons has shown to be worthy of a trial. 

During the year 1865, two ancient subcoracoid dislocations came under 
my observation at Bellevue Hospital. One of these cases, in the person 
of James Thompson, set. 49, had existed two years or more. He was 
employed about the hospital as a carpenter, and has a tolerably useful 
arm. The second, in the person of Rosanna Casey, set. 32, had existed 
six weeks when she was admitted. Various attempts had been made to 
reduce the dislocation before admission. During the week following her 
admission, an attempt was made at reduction by Dr. Verona, an intelli- 
gent house surgeon, subsequently by Dr. James R. Wood, and at the end 
of three months the attempt was made by myself, before the class of 
medical students, the patient being each time under the influence of an 
anaesthetic. She was finally discharged with the bone still unreduced. 

Mary Coffee, set. 46, was admitted also to the Charity Hospital, in 
Feb. 1864, with the same dislocation, which had existed six months, 
having been mistaken at first for a fracture. I found her arm free from 
swelling or paralysis, and moving quite freely in its new socket, and de- 
clined to make any attempt at reduction. 

July 28, 1873, an Irishman, about 40 years of age, was admitted to 
St. Francis's Hospital with a subcoracoid dislocation of the humerus of 
eight or nine weeks' standing. The surgeon who first saw him believed 
that he reduced the dislocation, but several weeks later he found it was 
again out of place, and he tried ineffectually to reduce it. My own 
efforts, continued for au hour or more, were equally unsuccessful. 



DISLOCATION" OF THE HUMERUS FORWARDS. 669 

The two following cases are recorded in order that they may illustrate 
the apparent inutility of a successful reduction in some cases. 

William E. Disbrow, of Bridgeport, Conn., received a subcoracoid dis- 
location of the right arm, in consequence of a violent and direct blow, 
May 9, 1870. Dr. George Lewis, of Bridgeport, a very intelligent 
surgeon, reduced the dislocation within half an hour, the patient being 
under the influence of ether. The restoration of the bone was complete, 
and attended with an audible sound. The arm was subsequently very 
painful, and at the end of three weeks Mr. Disbrow consulted a "natural 
bone-setter," who manipulated the limb violently, and perhaps dislocated 
it. July 9, 1870, eight weeks after the original accident, I found the 
bone unreduced, and in the presence of a number of medical gentlemen 
at Charity Hospital, effected reduction. The patient was anaesthetized, 
and the reduction was accomplished only after considerable extension 
and manipulation had been practised ; the return of the bone to its socket 
being accompanied with a grating sensation. A thick pad was then placed 
in the axilla, and the arm and forearm secured across the front of the 
chest. Mr. Disbrow remained under observation for some time ; but it 
was soon evident that the head of the bone was gradually receding from 
the socket, and that he was not to have a very useful limb. 

Jan. 10, 1875, Leonard Ball, set. 40, was thrown from a carriage at 
Norwich, Conn., causing a subcoracoid dislocation of the left arm. Five 
days later Dr. Patrick Cassidy, of Norwich, reduced the dislocation, the 
reduction being accompanied with a grating sensation. Four days later 
Dr. Cassidy found the arm again dislocated, and he again reduced it. 
Feb. 11th, thirty-two days after the original accident, the arm was ex- 
amined by myself and other visiting surgeons at Belle vue. Some of the 
gentlemen doubted whether it might not be a fracture of the surgical 
neck of the scapula. In my opinion it was a dislocation. On the same 
day before the class, and under ether, I effected reduction by manipu- 
lation, very little extension being employed. The arm was, however, 
manipulated in various directions, and considerable adhesions were torn 
before success was attained, the bone returning to its socket suddenly, 
and with a grating sensation, while the heel was in the axilla, and I was 
pulling moderately upon the arm. No one doubted the fact of reduction; 
the arm was now done up as in the preceding case, and the patient re- 
manded to his ward. 

A few days later I found the head of the bone had receded from its 
socket, and was evidently tending to assume the position in which I first 
saw it; and the motions of the joint were very limited. He was dis- 
charged from the hospital after two or three weeks, and I have not seen 
him since. 

It is quite probable that among the successful cases of reduction of old 
dislocations of the shoulder, reported from time to time, many have com- 
pleted their history in a similar manner. Possibly there may have been 
in each of these examples a fracture of the inner lip of the glenoid cavity, 
a condition which has been verified in several autopsies of old shoulder 
dislocation. 

The rapid changes which often take place in the socket, and in the 
condition of the adjacent tissues, may also account for the difficulty 



670 DISLOCATIONS OF THE SHOULDER. 

which we often experience in reducing these dislocations, and of retain- 
ing them in place after reduction. In Professor Lister's case, already 
referred to, at the end of seven weeks there was a complete socket formed, 
smooth, cartilaginous, and partly bony; and strong fibrous bands had 
formed between the coracoid process, the surgical neck of the humerus, 
and the axillary artery, containing a spiculum of bone. 

§ 3. Dislocation of the Humerus Backwards. (Subspinous.) 

This form of dislocation has been seldom met with. Only two cases, 
according to Sir Astley Cooper, occurred in Guy's Hospital in thirty- 
eight years; but in the last edition of Sir Astley Cooper's treatise on 
Fractures and Dislocations, edited by Bransby Cooper, nine cases are 
mentioned. 1 Sedillot, 2 Malgaigne, Desclaux, 3 Van Buren, 4 W. Parker, 5 
Lepelletier, 6 Trowbridge, 7 Physick, Snyder, 8 Stephen Smith, and myself, 
have each seen one example. Examples have also been seen by Dupuy- 
tren, Arnolt, Best, Levacher, Berard, Fizeau, Velpeau, Fergusson, Kirk- 
bride, 9 and by Rogers. 10 

Dr. Stephen Smith's case was seen by myself ten days after the acci- 
dent, by courtesy of Dr. Smith. The patient, John Creswell, aet. 36, 
fell down a flight of stairs Sept. 11, 1871, striking on the front of his 
shoulder. A surgeon, who saw him a few hours after, thought it was 
simply a bruise. Sept. 21, he was an inmate of Belle vue Hospital. 
The head of the humerus could be distinctly seen in its new position, and 
there was a marked depression under the acromion process, especially in 
front. The elbow hung very slightly from the body, and scarcely more 
forwards than the opposite elbow. He could carry it forwards pretty 
freely, and a little out, but he could not carry it back. He suffered very 
little pain, and there was no swelling of the arm or hand. On the follow- 
ing day Dr. Smith reduced the dislocation easily, by pulling the arm 
forwards, and at the same time pushing upon the head from behind. Dr. 
Smith informs me, however, that the bone became displaced on the fol- 
lowing day ; but that it was easily reduced, and afterwards remained in 
place. 

Causes. — One of the patients mentioned in Mr. Cooper's book had his 
shoulder dislocated backwards in an epileptic convulsion ; one had fallen 
upon his shoulder ; another met with the accident while pushing a person 
violently with the arm elevated ; and a fourth, seen by Coley, was " pulled 
down by a calf which he was driving, a cord having been tied to one of 
the calf's legs, and being held fast by the man's hand." My own patient, 
Frederick Kretner, had his arm caught in machinery on the 11th of Jan- 
uary, 1860. The dislocation was discovered when I was preparing to 

1 A. Cooper, op. cit., p. 352. 

2 Sedillot, Amer. Journ. of Med. ScL, vol. xiii. p. 551, Feb. 1834. 

3 Desclaux, New York Journ. of Med., Nov. 1851, p. ,109, from Revue Medicale. 

4 Van Buren, ibid., Nov. 1851, p. 110. 

5 Parker, ibid., March, 1852, p. 186. 

6 Lepelletier, Amer. Journ. Med. Sci., vol. xvi. p. 526, from Arch. Gen., Nov. 1834. 

7 Trowbridge. Bost. Med. and Surg. Journ., vol. xxvii. p. 99. 

8 Gibson's Surgery. 9 New York Journ. Med., March, 1852. 
10 Amer. Med. Times, November 9, 1861, vol. v. p. 303. 



DISLOCATION OF THE HUMERUS BACKWARDS. 



671 



amputate the arm soon after the accident occurred. Desclaux's patient 
fell from a height with his arm in front of him. In the case seen by Dr. 
Parker, of New York, a woman, set. 60, had fallen forwards and struck 
upon the outside of her elbow, arm, and shoulder. No attempt was made 
to reduce it until the fourteenth day, she not having for some time called 
the attention of any surgeon to its condition. Trowbridge's patient was 
thrown from a horse, striking on the palm of his hand. 

Pathology. — Mr. Cooper has given us a careful account of the dis- 
section in the case of Mr. Complin, already alluded to, whose arm had 
been dislocated by muscular spasm. This gentleman was fifty-two years 
of age, and had been subject to epileptic fits, in one of which the shoulder 
was dislocated. Many attempts were made to reduce it, but although it 
seemed to be easily drawn into its socket by extension merely, yet, as 
soon as the force ceased, the head of the bone slipped again upon the 
dorsum scapulae, and in this situation it was finally permitted to remain 
until his death, which did not take place until five years after. In the 
mean time he was able to move the limb but very slightly, so that his arm 
w T as almost useless. 

Mr. Cooper, to whom the arm was sent after death, found the head of 
the bone resting under the spine of the scapula, and against the posterior 
edge of the glenoid fossa, where it had formed a slight depression, and 
the head itself had become somewhat changed in form by absorption. 
The tendon of the subscapularis muscle and the internal portion of the 
capsular ligament were torn at the point where the muscle was inserted, 
but the greater portion of the capsule remained, having been pressed back 
by the head of the bone. The supraspinatus was stretched, while the 
infraspinatus and teres minor were relaxed. The long head of the biceps 
was elongated, but not ruptured. The glenoid fossa was rough and 
irregular upon its surface, the cartilage being absorbed. 

The fact that the bone would not remain in place when reduced, was 
explained by the rupture of the subscapularis, and the consequent loss 
of antagonism to the action of the infra- 
spinatus and teres minor. 1 

The accompanying drawing is a copy of 
that furnished by Mr. Cooper, to illustrate 
the position occupied by the bone. 

I ought to mention that this case has 
been regarded by Vidal (de Cassis), Mal- 
gaigne, and others, as only subacromial, 
and as a variety of the dislocation back- 
wards, differing from that in which the 
head of the bone occupies a position under- 
neath the spine. But as I can see no 
difference except in the degree or extent 
of the displacement, I prefer not to regard 
the distinction made by these surgeons. 

Symptoms. — The signs of this accident 
are, a projection under the spine of the subspinous dislocation. 



Fig. 275. 




1 Sir Astley Cooper, op. cit., p. 354. 



672 DISLOCATIONS OF THE SHOULDER. 

scapula, produced by the head of the bone, the head being obedient to 
the motions of the arm ; a corresponding depression in front and under 
the outer extremity of the acromion process ; a wide space between the 
head of the bone .and the coracoid process, into which the fingers may 
be pushed deeply ; the axis of the shaft of the humerus directed upwards 
and outwards toward a point posterior to the glenoid fossa. The fore- 
arm is usually carried forwards across the chest, and the humerus rotated 
inwards, unless the subscapularis muscle is torn. Immobility exists, but 
the motions of the arm are not generally so much impaired as in either 
of the other dislocations ; and finally, as in all other dislocations of the 
humerus, the hand cannot be laid upon the opposite shoulder while the 
elbow touches the front or side of the chest. In Parker's case the 
elbow was thrown outwards, although the arm was carried very much 
across the chest. In Smith's case the arm was nearly vertical. Des- 
claux's patient held his hand upon his head, with his arm horizontally 
across his body. 

Usually the diagnosis will be easily made ; in my own and Smith's 
case the position of the head of the bone was easily recognized, but Sir 
Astley relates one case in which, on the morning following the accident, 
a surgeon was unable to discover the dislocation, and on the seventeenth 
day Bransby Cooper failed to make the diagnosis ; nor, indeed, on the 
twenty-third day did Sir Astley himself determine that it was a disloca- 
tion, until he had unexpectedly reduced it while manipulating upon the 
arm. In a second example, Sir Astley at first believed it to be a frac- 
ture, but a more careful examination showed it to be a dislocation back- 
wards. In this instance the limb could not be rotated outwards, as the 
subscapularis was not torn, and continued to offer resistance w r hen the 
arm was moved in this direction ; he was also suffering much more pain 
than did the other patients, owing, as Sir Astley thinks, to pressure 
upon the articular nerves. In the case of Mr. Collinson, also mentioned 
by Mr. Cooper, a surgeon, who saw the patient immediately after the 
accident, failed to discover the true nature of the injury ; and Trow- 
bridge's patient had suffered a dislocation several weeks before the nature 
of the accident was fully determined. 

Prognosis. — The reduction has always been sooner or later accom- 
plished, except in one instance ; in this case we have seen that the arm 
never recovered any considerable degree of usefulness. Mr. Collinson's 
arm, reduced on the second day, was restored to all of its functions 
within one month. Dr. Parker's patient had nearly recovered the com- 
plete use of her arm at the end of four weeks, although it was not re- 
duced until it had been out fourteen days. Sedillot succeeded in reduc- 
ing the dislocation in the case of his patient, at the end of one year and 
fifteen days. Lepelletier, after forty-five days. Trowbridge, after forty 
days ; and in this latter case we are informed that the arm was restored 
to usefulness. 

Treatment. — In the first case mentioned by Sir Astley Cooper, " the 
bandages were applied in the same manner as if the head of the hu- 
merus had been in the axilla, and the extension was made in the same 
direction as in that accident" (downwards and a little outwards). In 
less than five minutes the bone slipped into its socket with a loud snap. 



PARTIAL DISLOCATIONS OF THE HUMERUS. 673 

The second case was treated successfully in the same way. Mr. Dunn 
also having failed to reduce by pulling upwards, finally succeeded by 
pulling at the wrist downwards and forwards, while an assistant pushed 
the head of the bone toward the socket ; the heel was not placed in the 
axilla, which Mr. Bransby Cooper thinks would have only retarded the 
reduction. Smith succeeded by a similar manoeuvre. Mr. Key also 
failed to accomplish reduction while carrying the arm upwards and 
backwards, but when the patient had become faint, by placing the 
heel in the axilla and pulling downwards a minute or two, the bone 
was reduced. Vidal (de Cassis) recommends the same plan, namely, 
that we shall pull in the direction in w T hich we find the limb ; Trow- 
bridge employed the pulleys successfully, the extension being made 
downwards and forwards ; while Dr. Parker succeeded equally well 
with his patient, by " pulling the arm outwards, downwards, and 
slightly forwards." Counter-extension was at the same time made by 
a sheet in the axilla, and the head of the humerus was pushed toward 
the socket by the hand. In Mr. Collinson's case, the scapula was 
supported by a towel, while " gradual extension of the limb was made 
directly outwards, and then the arm being moved slowly forwards, 
the head of the bone was distinctly heard to snap into its socket." 
The time occupied was not more than two or three minutes. Rogers 
succeeded by N. R. Smith's method. Sir Astley, however, seems to 
give the preference to the method which succeeded so happily in the 
case of Mr. G., while he was still manipulating with a view to determine 
the character of the accident. " I readily reduced the bone," he re- 
marks, " by raising the hand and arm, and by turning the hand back- 
wards behind the head." In one other instance, having failed to re- 
duce it by slight extension outwards, he raised the arm perpendicularly, 
at the same time forced it backwards behind the patient's head, and 
the reduction was promptly effected. In the case of Kretner, I first 
attempted reduction by pressure directly upon the head of the humerus ; 
but failing, I proceeded to pull the arm with moderate force outwards 
and downwards, which procedure was attended w T ith immediate success. 
The patient was under the influence of chloroform. 

After the reduction, a compress should be placed against the head of 
the bone, and underneath the spine of the scapula, and this should be 
secured in its place by several turns of a roller. The forearm ought 
also to be placed in a sling, with the elbow thrown a little back of the 
centre of the body, so as to direct the head of the humerus forwards. 

§ 4. Partial Dislocations of the Humerus. 

Sir Astley Cooper has related in his treatise two cases of supposed 
incomplete luxation of the head of the humerus forwards ; and in con- 
firmation of his views he has added an account of the appearances pre- 
sented on dissection in the body of a subject brought into the rooms of 
St. Thomas's Hospital. Bransby Cooper, in his edition of the same 
work, furnishes the report of a similar case which came under the ob- 
servation of Mr. Douglass, of Glasgow. Hargrave and Dupuytren have 



674 DISLOCATIONS OF THE SHOULDER. 

each reported one example of this species of dislocation, in which its 
existence was said to be confirmed by dissection. 

Petit, Duverney, Chopart, Sedillot, Miller, Gibson, Malgaigne, and 
many others, have admitted its possibility ; Malgaigne, however, only 
admits its existence when the capsule remains entire. 

Without intending to discuss very much at length the value of these 
opinions, I shall content myself with declaring that the existence of 
this or of any other form of partial luxation of the shoulder-joint, as a 
traumatic accident, has not up to this moment been fairly established ; 
and that the anatomical structure of the joint renders its occurrence 
exceedingly improbable, if not absolutely impossible. 

The only example mentioned by Sir Astley Cooper, in which a dis- 
section was made, showed that the long head of the biceps had been 
ruptured, and that the capsule was torn, while the head of the humerus 
was resting under the coracoid process. We shall have no difficulty, 
therefore, in assigning it to its proper place as a complete subcoracoid 
dislocation. In Mr. Hargrave's case, also, the tendon of the biceps was 
torn ; while Dupuytren omits to mention what was the actual fact in re- 
lation to this tendon in the case seen by him, but it is distinctly stated 
that the head of the bone rested upon the ribs. Mr. Hargrave seems, 
therefore, to have described a case of rupture of the long head of the 
biceps, and it is probable that Dupuytren, who knew nothing of the pre- 
vious history of the subject, has given us a faithful account of a patho- 
logical dislocation, a result of disease, and not of a direct injury. 

If the head of the humerus is driven from its socket by violence, and 
remains thus displaced, it is, we assume, a complete luxation ; since it 
is only by having placed the semi-diameter of the head of the bone out- 
side of the margin of the glenoid fossa that it can be made for one 
moment to retain its abnormal position. To accomplish this amount of 
displacement upwards, or upwards and forwards, or directly forwards, 
the acromion or the coracoid process must be broken ; while its occur- 
rence in any other direction must involve at least a most extraordinary 
extension, if not an actual laceration, of the capsule. If we admit, with 
Malgaigne, that occasionally the capsule has been found capable of such 
extraordinary extension without actual rupture, we still are unwilling 
to regard this as a fair example of a partial dislocation, since the head 
of the bone no longer moves in its socket, being at no point in actual 
contact with the articular surface of the glenoid fossa. It is essentially 
a complete dislocation, according to all the admitted definitions of this 
term. 

It is quite probable that a majority of these accidents were ex- 
amples of rupture or displacement of the tendon of the long head of the 
biceps, the effect of which, as Mr. John G. Smith 1 and Mr. Soden 2 have 
shown by a number of dissections, is to allow the head of the humerus 
to be drawn upwards and forwards in its socket, until it is arrested by 
the two processes, and by the coraco-acromial ligament. Says Mr. 
Soden, " To enable the bone to maintain its equilibrium, it is necessary 

1 Amer. Journ. Med. Sci., vol xvi. p. 219, May, 1835, from Lond. Med. Gaz. 

2 Ibid., vol. xxix. p. 480, from Lond. Med. Gaz., July, 1841. 



PARTIAL DISLOCATIONS OF THE HUMERUS 



675 



Fig. 276. 



that the capsular muscles should exactly counterbalance each other ; 
and as there is no muscle from the ribs to the humerus to antagonize 
the upper capsular muscles" (that is, to draw the head of the humerus 
downwards), " it is suggested that this office is performed by the sin- 
gular course of the long tendon of the biceps, which, by passing over 
the head of the bone, when the muscle is put in action, tends to throw 
the head downwards and backwards ; it follows, therefore, that, the 
tendon being removed, the head of the bone would rise upwards and 
forwards." 

The drawing (Fig. 276) represents the case of displacement of the 
tendon of the biceps seen by Mr. Soden, and of which he had been per- 
mitted to make a dissection. 1 

I have myself frequently observed, and I have before, when speaking 
of the prognosis or results of dislocations, called attention to the fact, 
that the head of the humerus some- 
times remains for a long time after the 
reduction has been effected slightly 
advanced in its socket, so as to lead to 
a suspicion that it is not properly re- 
duced. Quite recently I have been 
consulted in the case of a lad about 
fourteen years of age, who had been 
subjected to the pulleys during four 
consecutive hours to accomplish a more 
complete reduction. 

The same thing, also, has been no- 
ticed by me occasionally where the 
shoulder had been subjected to a vio- 
lent wrench, but no actual dislocation 
had ever occurred. In either case the 
explanation is perhaps the same, the 
long head of the biceps has been 
broken or displaced ; or, when it follows a dislocation, some of the 
muscles inserted into the greater tuberosity have been torn from their 
attachments. I mean to say, that in these circumstances we may find a 
sufficient and perhaps the most frequent explanation; yet it is quite 
probable that, in a considerable number of cases, the laceration of the 
capsule, and the action of the muscles, are alone concerned in the pro- 
duction of this phenomenon. I have seen one example in the person of 
Mr. Craig, of Brooklyn, in which the tendon of the biceps suddenly re- 
sumed its position after the lapse of several days, and the prominence of 
the head of the humerus at once disappeared. David Prince, 2 Hewett, 3 
and Holmes have each reported one example of displacement of this 
tendon. 4 In Mr. Holmes's case, however, the coracoid process was 
broken also. 




Displacement of the long 



of the biceps. 



1 Pirrie's System of Surg., Anier. ed., p. 255 ; also, Sir Astley Cooper, edited by 
Bransby Cooper, Amer. ed., p. 363. 

2 Prince, St. Louis Med. and Surg. Journ., Nov. 1879. 
s , 4 Holmes's Surgery, 2 Lond. ed., vol. ii. p. 820. 



676 DISLOCATIONS OF THE SHOULDER. 

Alfred Mercer, of Syracuse, N. Y., in a very interesting paper on 
this same subject, relates several examples of forward displacement after 
injuries to the shoulder-joint, one of which, as being exceedingly perti- 
nent, I shall take the liberty of quoting. 

" Mrs. B., a well-developed woman, of full habit, aged fifty-six, seven 
years since was thrown from a carriage, dislocating her right shoulder, 
which was reduced a short time after the accident, but the shoulder was 
painful, and tender to the touch, and almost useless for months after. 
She could carry the arm forwards and backwards, but could not raise it 
from the side, or carry the hand behind her, or raise it to her head, for 
fourteen months. She has gradually gained better use of her arm, but 
now, July, 1858, she cannot raise her elbow from the side more than 
half-way to a horizontal position without assistance; but with assistance, 
the arm may be carried into any position without pain or resistance. 
Measurement shows no appreciable difference in the size or length of the 
arm, or size of the shoulder ; but the point of the shoulder is still tender 
to the touch, is prominent in front, and correspondingly flattened behind. 
The head of the humerus appears to rest against the outside of the 
coracoid process, but the fulness of habit obscures the diagnosis, com- 
pared with the other cases. Several doctors, at different times, have 
examined the shoulder ; some have said it was not properly reduced, and 
advised a suit for malpractice. 

" I examined the shoulder again in November last ; it presented the 
same general appearance, although the patient was much thinner in 
flesh from recent sickness. Some six weeks previous to this examina- 
tion, in a sudden and thoughtless effort to raise the arm above the head, 
the muscles unexpectedly obeyed the will ; since which time she has 
had perfect use of it, though the deformity still remains. She thinks 
she felt or heard a snap when the arm went up, but it was followed by 
no pain, soreness, or swelling." 1 

There cannot be much doubt, we think, that in this case, at least, the 
deformity and maiming were due in a great measure to a displacement 
of the long head of the biceps. 2 

If a displacement of the tendon necessarily causes a displacement of 
the head of the humerus, it might seem proper to infer that a rupture 
of the tendon would do the same. The only example of rupture of the 
tendon which has come under my observation does not confirm this 
opinion. 

James Wallace, aet. 46, a sailor, and a man of remarkable muscular 
development, while pushing a swing with his arms extended felt some- 
thing snap in his right arm, and the arm at once became powerless. 
The sensation of snapping was at a point about four and a half inches 
below the acromion process. The pain was like that caused by hitting 
a nerve ; on the following day there was an extensive ecchymosis over 
the upper end of the humerus, and the belly of the biceps was full and 
flabby. 

Wallace was examined by me at Belle vue in March, 1875, about 

1 Mercer, Buffalo Med. Journ., vol xiv. p. 641, April, 1859. 

2 Broomfield's Cliirurg. Observ., vol. ii. p. 76. 



PARTIAL DISLOCATIONS OF THE HUMERUS. 677 

eight months after the injury was received. The belly of the biceps 
had shortened upon itself, and made a very remarkable prominence on 
the front of the arm, but he could not render it firm by contraction. He 
could Hex the arm slowly, but not against any considerable resistance. 
The head of the humerus was not advanced in the socket. I could feel 
the tendon of the biceps in its groove, and inferred that the rupture took 
place near its insertion into the muscle. 

J. L. Petit has reported a similar case, in which the rupture was 
caused by the extension employed in an attempt to reduce a dislocation 
of the arm. 1 

Dr. Arpad G. Gerster, in a paper read before the Society of the Phy- 
sicians and Surgeons of the German Hospital and Dispensary of New 
York, Oct. 12,1877, on "Subcutaneous Injuries of the Biceps Bra- 
chii," 2 has made some historical notes and observations which seem de- 
serving a place in this connection. He says: " Older surgeons (Stanley, 
Brom field, Knox, Monteggia, for instance), up to the middle of this 
century, diagnosed as dislocations of the long head of the biceps, cases 
similar to the one related" (case of partial rupture of the tendon, and of 
the corresponding part of the sheath of the long head of the biceps). 
" They supposed that the tendon left its groove, and slipped upon the 
major tubercle. True, none of them ever found the tendon in its dislo- 
cated condition, but they assumed that a spontaneous reduction took 
place by a rotation of the humerus, before a competent judge could 
ascertain the nature of the injury. William Cooper and Boerhaave ac- 
cepted the possibility of such an injury. Fergusson expressed himself 
cautiously on the subject. Bardeleben, Pitha, and Volkmann deny its 
existence, referring to a series of exhaustive articles in the Gazette 
Hebdomaclaire (2d ser., iv. [xiv.], 21, 23, 25, 1867), written by Sarja- 
vay, which completely disposes of this •' mysterious luxation,' as Pitha 
sarcastically calls it." 

Gerster states, moreover, that Pouteau had long before doubted the 
existence of this dislocation, and that Malgaigne had expressed skepti- 
cism as to the true character of Mr. Soden's case. In short, Dr. Gerster 
claims that its existence, uncomplicated with other accidents, has never 
been demonstrated satisfactorily upon the living or dead subject; and 
that, to say the least, it is doubtful whether it has ever occurred. The 
entire argument, together with the anatomical reasons assigned, are very 
ingenious ; and while they do not settle conclusively in my own mind 
the question of its possibility, they seem to throw a doubt upon the true 
nature of some of the cases reported. 

1 Malgaigne, Up. cit., Paris ed., 1855, vol. ii. p. 145. 

2 Gerster', N. Y. Med. Joum., May, 1878, p. 487. 



678 DISLOCATIONS OF THE HEAD OF THE RADIUS 



CHAPTEE VII. 

DISLOCATIONS OF THE HEAD OF THE RADIUS 
(HUMERO-RADIAL). 

I HAVE recorded thirty-two examples of traumatic dislocation of the 
head of the radius as having been seen and examined by me ; of which 
twenty-seven were dislocated forwards, or forwards and outwards, and 
only five backwards : or, rejecting those cases w r hich were complicated 
with fracture, I have recorded fourteen cases of simple forward luxation, 
and three of simple backward luxation. My experience, therefore, does 
not correspond with the experience of Boyer, Velpeau, Vidal (de Cassis), 
Chelius, B. Cooper, Guthrie, Gibson, and some others, who declare that 
the dislocation backwards is the more frequent of the two. Indeed, I 
ought to say of two of the examples of backward luxation of the radius 
which have come under my notice, and which I have marked as simple, 
that they were ancient luxations ; and I am not entirely certain, there- 
fore, that they had not been originally complicated with a fracture, 
although at the time of my examination they presented no such evidence. 
The third, which I believe to have been a genuine, simple backward dis- 
location, I will mention again in connection with this latter form of dis- 
location. I have seen one congenital dislocation of the head of the 
radius outwards and forwards, which I will describe more particularly in 
the chapter on congenital dislocations. 

1 1. Dislocations of the Head of the Radius Forwards. 

Causes. — A fall upon the elbow, the blow being received directly upon 
the posterior face of the head of the radius ; a fall upon the hand with 
the forearm extended and pronated ; extreme pronation of the forearm ; 
or, according to Denuce, a blow upon the inside of the elbow, which is 
equivalent to a violent adduction of the forearm. 

In children, and especially in those of a strumous habit, whose liga- 
ments are feeble, a subluxation forwards, or even a complete luxation, is 
occasionally produced by being lifted suddenly from the floor by the hand, 
or by an attempt to sustain the child when he is about to fall. I have 
seen examples of this dislocation produced in this way. Batchelder, 1 
Sylvester, 2 Goyrand, 3 and many other surgeons, have mentioned similar 
cases. In the case of Lydia Merton, four years old, brought to me in 
May, 1868, the dislocation was caused by holding on by the hands after 
having fallen from a swing. 

' New York Journ. Med., May, 1856, p. 333. 

2 Amer. Journ. Med. Sci., vol. xxxi. p. 206, Jan. 1843. 

3 Ibid., vol. xxxii. p. 228, July, 1843. 



DISLOCATIONS OF HEAD OF RADIUS FORWARDS. 679 

Dr. Krackowizer related to the New York x\cademy, in 1856, a case 
of complete dislocation forwards, produced, as was supposed, in the act 
of turning the child in delivery. The arm was ecchvmosecl, and the dis- 
location was very distinct. 1 

Pathological Anatomy. — The head of the radius is carried forwards 
upon the humerus, and generally a little outwards. In the case of Lydia 
Merton, already mentioned, the head of the radius, on the ninety-fourth 
day after the accident, was nearly in the centre of the humerus. The 
anterior and external lateral ligaments, with the annular, are in most 
cases more or less broken. Sometimes the anterior and external lateral 
are alone broken, the annular ligament being then sufficiently stretched 
to allow of the complete dislocation ; or the anterior and annular having 
given way, the external lateral may remain intact. 

Symptoms — The head of the radius can in general be distinctly felt in 
its new situation, rotating under the finger when the hand is pronated and 



Fig. 277. 



Fig. 278. 





Head of the radius forwards. Anatomical 
relations. 



Head of radius forwards. External appear- 
ance of limb. 



supinated ; we may sometimes also recognize a depression corresponding 
to its natural situation, behind and below- the little head of the humerus. 
The external border of the forearm is slightly shortened, and the arm 
inclines unnaturally outwards. The tendon of the biceps is relaxed. 



1 Krackowizer, New York Journ. Med., March, 1857, p. 262. 



680 DISLOCATIONS OF THE HEAD OF THE RADIUS. 

The forearm is generally pronated, sometimes it is in a position midway 
between supination and pronation, but I have never seen it supinated. I 
have particularly noticed this fact in my report made to the New York 
State Medical Society in 1855 ; and Denuce, who has also examined 
these cases carefully, affirms that it is seldom supinated, notwithstanding 
the general statements of surgeons to the contrary. 

The arm is usually a little flexed, and cannot be perfectly extended 
without causing pain. In some cases, especially when the dislocation 
has existed for a considerable length of time, the arm is capable of 
extreme and unnatural extension. This was the case with Lydia 
Merton. There is usually preternatural lateral motion ; but, except in 
old cases, the forearm cannot be flexed upon the arm beyond a right 
angle. 

Prognosis. — Denuce says : " The reduction is often impossible ; more 
frequently still, difficult to maintain." In proof of which he refers to 
the observations of Danyau and Robert. In the case of recent luxation 
related by Robert, it was found impossible to maintain a reduction which 
he thought he had several times accomplished, and he believed that the 
difficulty consisted in a portion of the torn annular ligament having be- 
come entangled between the head of the radius and the condyle of the 
humerus. 1 

Sir Astley Cooper was unable to accomplish the reduction in two 
recent cases ; and of the six cases which came under his immediate ob- 
servation, only two were ever reduced. In Bransby Cooper's edition 
of Sir Astley's work, other similar examples of non-reduction are 
related. 

Malgaigne says that in a collection of twenty -five cases which he has 
made, the accident was unrecognized or neglected in six, and ineffectual 
efforts at reduction had been made in eleven ; so that only eight of the 
whole number were reduced. 

I have myself met with six of these simple dislocations which were 
not reduced, three of which, however, had not been recognized, and no 
attempt at reduction had ever been made ; one had been treated by an 
empiric, Sweet, a " natural bone-setter," but without success ; one had 
been reduced, but it had become reluxated, and in the remaining ex- 
ample I was unable to reduce the dislocation on the seventh day. 

The following are brief notes of four of these cases : — 

A young man, set. 23, presented himself at my office, to whom the 
accident had occurred about one year before. The surgeon who was 
first called did not recognize the dislocation, and no attempt had ever 
been made to replace the bones. The forearm was forcibly pronated 
and could not be supinated, but he could extend it completely, and flex 
it somewhat beyond a right angle. It was strong, and nearly as useful 
as before. 

H. H. B., set. 6 ; dislocation produced by a fall upon the elbow. 
The surgeon who was called did not detect the nature of the injury. 
Eighteen years after, I found the head of the radius lying in front of 
the old socket, having formed a new socket, in which it moved freely. 

1 Memoire sur les Luxations du Coude, par Paul Denuce. Paris, 1854. 



DISLOCATIONS OF HEAD OF RADIUS FORWARDS. 681 

From the elbow to the hand the arm inclined outwards, or to the radial 
side ; pronation and supination were perfect. He could flex the arm to 
an acute angle, but not so completely as the other. The arm was as 
strong as the other, but it was frequently hurt by lifting. 

Ira E. Irish, set. 12, had a dislocation of the head of the radius for- 
wards. An empiric named " Sweet" was at first employed, but failed to 
reduce it. Thirty-nine years after, when Mr. Irish was fifty-one years 
old, I examined the arm. He could not flex the forearm upon the arm 
beyond a right angle ; and when the attempt was made, the radius 
struck against the humerus. Complete supination was impossible. The 
arm was as strong as the other, except in raising a weight above his 
head. Occasionally he was annoyed with slight pains in this limb. 

Urias Lett, a colored barber of Buffalo, aged forty-eight years, was 
thrown from a carriage, producing a dislocation of the right radius, and 
severely bruising the elbow-joint. He did not see a surgeon until six hours 
had elapsed. The elbow was then much swollen, and exquisitely tender, 
and Lett would not permit much if any examination, to determine its con- 
dition. The doctor applied simple dressings, and the next day requested 
me to see him. The whole arm was then swollen and tender, and very 
little examination was admissible. The dressings were, therefore, not 
completely removed, but only laid open sufficiently to enable us to see the 
joint. We suspected a forward luxation of the head of the radius, but 
could not positively determine the point — the patient not permitting any 
kind or degree of manipulation. We decided, therefore, to wait a few 
days until the inflammation had somewhat abated, and then, if the ex- 
istence of a dislocation was ascertained, to attempt its reduction. On 
the seventh day the swelling had measurably subsided, and the diag- 
nosis became satisfactory. We immediately placed him under the com- 
plete influence of chloroform, and made long-continued and violent 
efforts at reduction, but without success. Severe inflammation again 
followed these efforts, and Lett would never consent to another trial. 
After four years, I find the bone still out. He can flex the forearm 
upon the arm almost as far as he can the opposite limb ; he can carry it 
nearly to his mouth, the head of the radius sliding off upon the outer 
face of the humerus, and not resting plumply against it; indeed, the 
radius seems to have been gradually pushed outwards as well as for- 
wards. The hand is forcibly pronated, and cannot be supinated. The 
attempt to supine produces a click in the neighborhood of the head of 
the radius, as if it struck against a bone. The arm is as strong as the 
other, and not wasted. He has constantly pursued his occupation as a 
barber, after only a few weeks' confinement. 

If the dislocation is accompanied with a fracture of the ulna, unless 
the fracture is transverse or incomplete, reduction is not generally ac- 
complished. When speaking of fractures of the shaft of the ulna, I 
have related several examples illustrative of this remark. Norris has 
made the same observation. 1 I have, however, three times met with 
this accident thus complicated in children, in the treatment of which a 

1 Xorris, Ainer. Journ. Med. Sci., vol. xxxi. p. 21. 
44 



682 DISLOCATIONS OF THE HEAD OF THE RADIUS. 

much better result has been obtained. In the first example, a lad aged 
nine years had broken the ulna in its upper third and dislocated the 
radius forwards. Dr. White, of Buffalo, and myself were in immediate 
attendance. Both the fracture and dislocation were easily reduced, 
and in a few weeks the limb was sound and perfect, except that a slight 
fulness remained in front of the head of the radius, and this continued 
for several years. In the second example, a lad, of the same age as the 
other, was treated by Dr. Austin Flint and myself. We reduced both 
the fracture and the dislocation by extending the arm from the wrist, 
while at the same moment pressure was made upon the head of the 
radius from before backwards. A right-angled splint was applied and 
continued during a period of four weeks, being removed daily for the 
purpose of giving to the joint gentle, passive motion, etc. After this 
the arm was permitted to straighten gradually, and at the end of a 
month more the joint was moving freely, and with no degree of displace- 
ment at the point of fracture or dislocation. 

It is quite probable that in each of the above cases the separation was 
not complete, although crepitus was distinct, and the displacement of the 
broken ends was very marked. In the following case the fracture was 
certainly incomplete : — 

Elizabeth Carmody, set. 4, was brought to me, August 6, 1851, with 
a fracture of the ulna, two inches below its upper end, the fragments 
being inclined backwards, while the radius was dislocated forwards. 
Both bones were easily replaced, and the functions of the arm were 
soon completely restored. This case was erroneously reported to the 
New York State Medical Society as an example of fracture of the radius, 
with dislocation. 

Where the restoration has been promptly effected and maintained 
steadily, the motions of the joint are soon restored ; but in one case the 
head of the radius has been found to play very freely and loosely after 
the lapse of two years, and in others it has remained slightly prominent 
in front, as if it was a little in advance of its socket. 

Treatment. — Extension and counter-extension should be made in the 
direction in which we already find the limb, namely, with the forearm 
slightly bent upon the arm, while at the same moment the surgeon should 
seize the elbow with his hands ? and press the head of the radius back 
with his two thumbs. 

Other methods will often succeed ; but by this we relax the biceps, 
and put the parts in the best position to accomplish the reduction easily 
and promptly. Sir Astley directed to supine the forearm while the 
extension was being made from the hand, but Denuce prefers that the 
forearm should be in a position of pronation. 

After the reduction is effected it is never safe to straighten the arm 
completely at once, nor indeed for some weeks ; not until the ligaments 
have been sufficiently restored to resist the action of the biceps. The 
arm must therefore be flexed and placed in a sling, or, if the radius is 
disposed to become reluxated, a right-angled splint ought to be placed 
upon the back of the arm and forearm, and, by the aid of a compress 
and roller, an attempt should be made to retain it in place. 



DISLOCATION OF HEAD OF RADIUS BACKWARDS. 683 

Nor will it be found safe at any period to compel the arm by force 
to resume the straight position, since this bone, when it has once been 
dislocated, will for a long time be liable to luxation. 

A boy, aged about four years, was presented at my clinic by his 
father, having a forward dislocation of the head of the radius. The dis- 
location had existed several months. The father's purpose in bringing 
the child was to ascertain whether he could not claim damages for mal- 
practice. The account which he gave was as follows : The surgeon 
called it a dislocation forwards, and pretended to reduce it. A right- 
angled splint was applied with a roller. At the end of three weeks the 
father removed the splint, but did not discover anything out of place. 
Finding, however, that the elbow was stiff, he took measures to straighten 
it forcibly. In a few days he discovered the head of the bone out of 
place, and so it has remained ever since. 

I explained to him that there was much reason to suppose that the 
surgeon had properly reduced the dislocation, and that he had himself 
reproduced the accident, by straightening the arm, through the action of 
the biceps upon the upper end of the radius. The father declined any 
further surgical interference, and no prosecution has followed. 

The late Dr. Batchelder, of ISTew York, in a very excellent paper on 
dislocations of the head of the radius, has described a method of reduc- 
tion suggested to him first by Dr. Goodhue, of Chester, Vermont, and 
which he had himself found more successful than any other method ; 
indeed, he says it never fails, yet he does not inform us in precisely how 
many cases he had made the trial. The plan suggested by Dr. Good- 
hue consists essentially in first making extension from the hand, and 
pressing at the same time doAvnwards and backwards upon the head of 
the radius until it has descended to a level with the articulating surface 
of the humerus. As soon as this is accomplished, the forearm is to be 
suddenly flexed upon the arm in such a direction as that the hand shall 
pass outside of the shoulder ; at the same moment, also, the pressure 
must be continued vigorously upon the head of the radius. 1 

§ 2. Dislocation of the Head of the Radius Backwards. 

Denuce has collected fourteen examples of this luxation ; but Mal- 
gaigne, who rejects a portion of the cases, and adds one or two more, 
admits only twelve. In addition to those mentioned by these two 
writers, I have found recorded, or incidentally noticed, one by May, 2 
one by Bransby Cooper, 3 one by Lawrence, 4 one by Liston, 5 two by 
Case, 6 two by Gibson, 7 one by Parker, 8 three by Markoe, 9 two by Con- 

1 Goodhue, New York Joum. of Med., May, 1856, p. 333. 

2 May, Sir Astley Cooper on Dislocations, etc., by B. Cooper, op. cit., p. 403. 

3 B. Cooper, ibid., p. 404. 4 Lawrence. Pirrie's System of Surgery, p. 259. 

5 Listou, Practical Surgery, p. 88. 

6 Case, Amer. Journ. of Med. Sci., vol. vi. p. 254, from lltb No. of Provincial Med. 
Gazette. 

7 Gibson, Institutes and Practice of Surgery, 6th ed., vol. i. p. 379. 

8 Parker, New York Journ. of Med., March, 1852, p. 188. 

9 Markoe, ibid., May, 1855, p. 382. 



684 DISLOCATIONS OF THE HEAD OF THE RADIUS. 

ner, 1 one by Mack, 2 and one by Bivington, 3 and to these my own 
observations have added five more, in all thirty -three supposed examples. 

Of the examples brought under my own notice I have already in the 
preceding section affirmed that two of them were accompanied with frac- 
ture, and I am not entirely certain but that they all but one were. 
Markoe, of New York, whom we have mentioned as having reported 
three cases, found in each case a fracture of the internal condyle of the 
humerus, and, after an examination of a number of the reported ex- 
amples, he does not find any evidence that this dislocation ever occurs 
as a simple uncomplicated accident. It seems quite certain, however, 
that the backward dislocation does so occur, yet it is no doubt exceed- 
ingly rare ; but the following case, of which I have only brief notes, 
must be accepted as a genuine example, inasmuch as the mode of its 
occurrence seems to preclude a fracture : Frederick Kuger, of New York, 
was seen by me December 7, 1879, when he was fifteen years old, 
having a dislocation of the head of the left radius backwards, which 
the mother stated was caused by a convulsion when he w r as one year 
old. The button-like head of the radius could be distinctly felt, and 
there was no evidence of any other injury. 

The example reported by Parker as having happened in the practice 
of 1ST. K. Freeman, of this city, is one of the few also which seems to 
admit of but very little doubt. 

In July, 1850, Dr. Freeman was called to see a gentleman, set. 37, 
who was seriously injured by jumping from the railroad cars while they 
were in motion, and found a backward luxation of the head of the radius 
of the right arm. " The symptoms," says Dr. Freeman, " were marked ; 
the hand and forearm were prone, and the attempt to place them in the 
supine position caused great pain ; while the head of the radius formed 
a considerable projection posterior to the external condyle of the hume- 
rus, where the cavity on its extremity could be distinctly felt. Assisted 
by Dr. Walsh, of Fordham, who firmly grasped the humerus, I was 
enabled to reduce it by extending the forearm and flexing it upon the 
arm, at the same time pronating the hand, and pressing forwards the 
head of the radius with my thumb. After the reduction was effected, 
I requested Dr. Walsh to examine it ; when, upon slight extension being 
made upon the forearm, with supination of the hand, the bone was again 
dislocated. I immediately reduced it in the same manner as before, 
and directed the patient to keep the forearm flexed and the hand prone, 
and, laying it upon a pillow, apply cold water. He complained of se- 
vere pain for two days, which gradually subsided, and on the fourth day 
he was able to move and extend the forearm." 

The case reported to me originally by Dr. Mack, of Waterloo, Iowa, 
and already referred to as published in the Record, appears to have been 
clearly made out. 

Causes. — The usual causes are, a direct blow upon the front and upper 
part of the radius ; a fall upon the elbow, or upon the hand ; a violent 

1 P. S. Conner, The Clinic, Aug. 15, 1874. 

2 C. J. Mack, The Med. Record, Dec. 2, 1876, p. 779. 

3 Rivington, Lond. Hosp., Lancet, Dec. 27, 1879. 



DISLOCATION OF HEAD OF RADIUS OUTWARDS 



685 



Fig. 27! 



effort to supinate the forearm while it is grasped and held firmly in a 
state of pronation ; and probably it is sometimes occasioned by a twist- 
ing of the arm in machinery, etc. 

Pathological Anatomy. — In the only example, so far as I know, of 
which a dissection has been made, reported by Sir Astley Cooper, " the 
coronary ligament was found to be torn through at its forepart, and the 
oblique had given way. The capsular ligament was partially torn, and 
the head would have receded much more, had it not been supported by 
the fascia which extends over the muscles of the forearm." The head 
of the radius was thrown behind the external condyle of the humerus, 
and rather to the outer side. This was an ancient luxation found in the 
dissecting-room of St. Thomas's Hospital, and the accompanying drawing 
is copied from the sketch made at the time. 

If the luxation is not complete, as occasionally happens with children, 
the annular ligament may not be torn. 

Symptoms. — The head of the bone is felt rotating behind the outer 
condyle, and a depression exists corresponding to its original position. 
The forearm is slightly flexed and prone ; and the 
whole arm is deflected outwards from the elbow 
downwards ; flexion and extension are difficult, 
while supination is impossible. 

Treatment. — Most surgeons have taught that 
while extension and counter-extension are being 
made, the forearm should be forcibly supinated, and 
that at the same time the head of the radius must 
be strongly pushed forwards. Martin recommends 
to extend forcibly, and then suddenly flex the 
arm ; in a manner very similar to the plan rec- 
ommended by Batchelder in dislocations forwards. 
In Dr. Freeman's case, just quoted, the reduction 
was effected while the forearm was pronated, and 
supination seemed to throw it again out of place. 
Dr. Middleditch, in the case reported by Mack, 
succeeded in his first effort, by making extension, 
with the arm flexed to a right angle, while pres- 
sure was made upon the head of the radius. 

According to Markoe, where the accident is 
complicated with a fracture of the inner condyle, 
when the reduction is accomplished the arm 
should be placed in a position about ten degrees less than a right ano-le, 
and supported by a splint with bandages, etc. 

If the dislocation is simple, however, I can see no objections to its 
being nearly or quite extended, since in this dislocation the action of the 
biceps would only tend to retain the head of the radius in place. 




Dislocation of the head of 
the radius hackwards. 



§ 3. Dislocation of the Head of the Radius Outwards. 

Demice* has collected four examples of this accident, unaccompanied 
with a fracture, and he proceeds to speak of it as a distinct form of dis- 
location. In two of the examples, however, mentioned by him, it was 



686 DISLOCATIONS OF THE UPPER END OF THE ULNA. 

consecutive upon a forward luxation, and I have several times seen the 
head of the radius very much inclined outwards in what are properly 
termed forward dislocations. For these reasons it is not very plain to 
me that we ought to consider this as a distinct form of primary disloca- 
tion, but rather as a consecutive luxation, or at least as only a modifica- 
tion of the forward or backward luxation. Indeed, I think the radius 
never will be found thrown directly outwards, but always in a direction 
inclining forwards or backwards. 

Parker, of this city, mentions a case w T hich came under his notice, in 
a child four years old, who, six weeks before, had fallen down stairs 
" backwardly, with the right arm twisted behind the back, in such a 
position that the whole weight of her body came upon her arm." No 
attempt was ever made to reduce the bone, and the head of the radius 
continued to project externally. By pressure it was easily reduced, but 
became immediately displaced when the forearm was either flexed or ex- 
tended. The motions of the joint were comfpletely restored. Dr. Parker 
recommended no treatment. 1 



GHAPTEE VIII. 

DISLOCATIONS OF THE UPPER END OF THE ULNA 
(HUMERO-ULNAR). 

Dislocation Backwards. 

This accident, the existence of which, as a simple luxation, is placed 
beyond doubt, has nevertheless been described so variously, and often 
indefinitely, that it is impossible to declare its history, except in a few 
points, with any degree of accuracy. No doubt many of the cases which 
have been reported were examples only of a subluxation of both radius 
and ulna backwards. In other cases, the radius or the external condyle 
of the humerus being broken, the ulna has been actually displaced, not 
only backwards, but upwards ; indeed, it is very certain that without 
either a luxation of the radius, or a fracture with displacement of the 
external condyle of the humerus, or a fracture or bending of the radius, 
an upward displacement of the ulna, to the degree represented by the 
reporters of these cases, could never have occurred. The example men- 
tioned by Sir Astley Cooper, and of which a dissection was made, is 
plainly a case of subluxation of both bones ; or if the luxation of the ulna 
may be regarded as having been complete, the head of the radius was 
also displaced more or less upwards from its original socket; a new 
socket, Sir Astley himself informs us, having been formed for its recep- 
tion, upon the external condyle. But this is the only example, the actual 
condition of which has been proven by an autopsy. 

Nevertheless, it seems probable that a simple luxation or subluxation 

1 Parker, New York Journ. Med., March, 1852, p. 189. 



DISLOCATIONS OF THE RADIUS AND ULNA. 687 

of the ulna backwards may occur without either of the above-mentioned 
complications, and that, to the extent of a few lines, it may be made to 
pass upwards upon the back of the humerus, by the falling of the fore- 
arm to the ulnar side ; in which case the character of the accident would 
probably be recognized by the projection of the olecranon process, while 
the head of the radius might be felt moving in its socket ; by the par- 
tial flexion and complete pronation of the forearm, and by the general 
immobility of the joint. In a case reported by Dr. Waterman, caused 
by a fall on the hand, the arm was at a right angle, and pronated. 1 

Its reduction ought to be accomplished easily, one would think, by the 
same measures which have been found successful in reducing a disloca- 
tion of both bones backwards ; but in "Waterman's case this method 
failed, and the reduction was promptly effected by bending the forearm 
forcibly back. 

Fig. 280. 




Dislocation of the upper end of the ulna backwards. 

Pirrie says that in a case occurring in the practice of Mr. Gosset, in 
which the coronoid process rested on the internal condyle, and the pain 
on bending the arm was insupportable, owing, it was supposed to the 
pressure of the coronoid process against the ulnar nerve, " reduction 
was accomplished by extension and counter-extension applied by two 
persons pulling in opposite directions, and by the pressure of the ole- 
cranon process downwards and outwards, while the forearm was sud- 
denly flexed." 2 



CHAPTEE IX. 

DISLOCATIONS OF THE RADIUS AND ULNA (FOREARM) AT THE 

ELBOW-JOINT. 

The radius and ulna may be dislocated at the elbow-joint backwards ; 
laterally, that is, either inwards or outwards ; and forwards. 

§ 1. Dislocation of the Radius and Ulna Backwards. 

Causes. — My records of private and hospital practice supply seventy- 
two cases : the youngest being four years old, and the oldest sixty-one. 

1 Boston Med. and Snrg. Journ., vol. iv., new series. 

2 G-osset, Pirrie's Surg., Arner. ed. ? p. 259. 



688 



DISLOCATIONS OF THE RADIUS AND ULNA 



Fig. 281. 



Twenty-nine of this number occurred in children under fourteen years of 
age. 

Generally the dislocation has been produced by a fall upon the palm 
of the hand, as when in running a person has fallen forwards with the 
forearm extended in front of the body, or he may have fallen from a 
height ; once I have known it produced by a blow received upon the back 
and lower part of the humerus ; and in several instances the patients 
have declared that they had fallen upon the elbow ; it is produced, occa- 
sionally, by twisting the forearm violently, as when the limb has been 
caught and wrenched about by machinery, by a blow upon the front and 
upper part of the forearm, and by forced flexion. 

Pathology. — The radius and ulna are not only carried backwards 
behind the articulating surface of the humerus, but they are also, 

through the action of the triceps, almost 
always drawn more or less upwards, so that 
often the coronoid process of the ulna rests 
in the olecranon fossa. In some cases it has 
been known to mount even higher, while in 
others it is arrested short of this point. The 
radius still retaining its relative position to 
the ulna, lies upon the back of the humerus, 
or rather upon the posterior margin of its 
articulating surface. 

The anterior and two lateral ligaments are 
generally more or less completely torn asun- 
der ; but the posterior ligament and the annu- 
lar do not usually suffer disruption. 

The biceps muscle is drawn over the lower 

articulating surface of the humerus, but is in 

a condition of only moderate tension, while 

the brachialis anticus is forcibly stretched, 

or even torn. Malgaigne says the tendon of the biceps has once been 

found behind the humerus. 

The median nerve is also pressed upon in front by the humerus, and 
the ulnar is occasionally painfully stretched over the projecting extremity 
of the ulna from behind. 

Symptoms. — Sir Astley Cooper does not mention particularly the 
position of the arm as to flexion or extension, except to say that " the 
flexion of the joint is in a great degree lost ;" nor, in his original work, 
published in London in 1823, is there any illustration accompanying 
the text to indicate in what position he had usually seen the limb ; but 
in the later editions, edited by Mr. Bransby Cooper, is found a drawing 
which represents the forearm at a right angle with the arm. It is very 
certain that Sir Astley never sanctioned this error by anything which 
he had written or communicated to others. It is very certain, I say, 
because the fact that it seldom, if ever, occupies this position, could 
not have escaped the notice of one whose experience was so large, and 
whose habits of observation were generally so accurate. The truth is 
that it is almost constantly found only slightly flexed, or forming an 
angle in front of about 120°. 




Dislocation of the radius and 
ulna backwards. 



DISLOCATION OF RADIUS AND ULNA BACKWARDS. 689 

This fact is especially noticed in my records twenty-six times, and, 
if it had ever been found in any other position, it would certainly have 
been stated. Once, where the dislocation was accompanied with a 
fracture of the outer condyle of the humerus, the arm was at first 
straight, a position in which it is said to be found occasionally with 
children ; and in the case of a patient admitted to Bellevue Hospital, 
on the 14th of December, 1864, the dislocation having existed thirty- 
one days, but unaccompanied with a fracture, I found the arm straight, 
and there existed also a preternatural lateral mobility of the elbow- 
joint ; but never, in any case of a recent dislocation, and but once in 
an old dislocation, have I found it flexed to a right angle ; yet I will 
not deny that such unusual phenomena are possible in recent disloca- 
tions ; indeed, it is certain that they have occasionally been presented, 
but they must be regarded as only exceptional, and as by no means 
diagnostic of this accident. 

Sir Astley Cooper and Miller declare that in this dislocation the 
forearm is usually supinated ; Pirrie says " the hand is between prona- 
tion and supination, but more inclined to the latter." Desault thinks 
it is sometimes in supination and sometimes in pronation ; Denuce con- 
cludes that it will occupy that position, whatever it may be, in which 
the force of the blow has thrown it ; while by most surgical writers no 
allusion is made to the position of the forearm in reference to pronation 
or supination. For myself, I can only say that I have found the fore- 
arm and hand almost constantly in a position of moderate but positive 
pronation, and I am compelled to regard it, therefore, as one of the 
usual signs of a backward dislocation of these bones. 

The limb can be neither flexed nor extended without force, and such 
motion is almost always accompanied with pain. It is, however, possible 
in most cases to give to the arm a slight lateral motion, such as does not 
belong to it in its natural condition. 

In front, and deep in the fold of the elbow, is felt the lower end of 
the humerus, forming a hard, broad, and somewhat irregular projection, 
over which the integuments and muscles are swollen, and tender to 
pressure. Behind, the head of the radius may be felt, when not much 
tumefaction exists, rotating or moving under the finger when the fore- 
arm is supinated and pronated ; while the olecranon process projects 
strongly backwards and upwards. If now we flex the arm slightly, 
this projection of the olecranon process will be sensibly increased ; but, 
if an attempt is made to straighten the arm, it will be diminished, the 
reverse of what we have seen to happen in cases of fracture of the lower 
end of the humerus (at the base of the condyles). This circumstance 
becomes, therefore, an important diagnostic mark between these two 
accidents. 

The relation of the olecranon process, also, to the condyle is changed, 
and the upper end of this process, instead of being a little below the in- 
ternal condyle, as it would be naturally when the arm is slightly flexed, 
is found generally carried upwards toward the shoulder, from half an 
inch to one inch or more above the condyle. 

Measuring from the internal condyle to the styloid process of the 
ulna, the forearm is shortened ; the same result will be obtained also by 



690 DISLOCATIONS OF THE RADIUS AND ULNA. 

measuring from the acromion process to either of the styloid processes ; 
while from the acromion process to the condyle, the length will be the 
same in both arms. 

The signs which have now been enumerated will be sufficient to 
enable us to make the diagnosis promptly in the great majority of 
cases, but, if considerable swelling has already taken place, the diag- 
nosis may be rendered exceedingly difficult, if not impossible ; and in 
such cases we should confine the patient at once to his bed, and proceed 
to reduce the tumefaction by appropriate means as rapidly as possible, 
examining the limb carefully from day to day in order that we may 
seize the earliest opportunity to ascertain its actual condition and to 
effect the reduction. 

In relation to the difficulty of diagnosis in certain examples of this 
accident, and under certain circumstances, Mr. Skey, in his Operative 
Surgery, has made some very judicious remarks. 

"Severe injuries of the elbow-joint, whether in the form of fracture, 
dislocation, or a compound of the two, are frequently followed, at a 
short interval, by swelling of a formidable kind, in which it is impos- 
sible, but by the aid of a perfect intimacy with the anatomical structure 
of the joint, to detect the relations of one part with another: but even 
under this difficulty, the two points in question are readily distinguish- 
able. In such forms of swelling, the arm, including the length of six 
inches both above and below the joint, may be involved in the extrava- 
sation, and this swelling may distend the arm to a circumference of one- 
third beyond its natural size. In such circumstances, in which it is 
impossible to determine with any certainty whether any, or what bones 
are broken, or whether or not dislocated, the difficulty of the case should 
at once be stated to the friends of the patient." 

Prognosis. — If the luxation is recent, reduction is in general easily 
effected; but if considerable time has elapsed, the reduction is often ac- 
complished with difficulty. As to the probability of its reluxation, I 
have already spoken when considering the subject of fractures of the 
coronoid process. Unless this process is broken, it is not likely to occur 
except where some violence has again been applied. It has happened 
to me, however, to find these bones unreduced in several instances. In 
some of these examples surgeons recognized the accident and supposed 
that they had accomplished reduction, while in others the dislocation was 
mistaken for a fracture. 

A lad, W. F., twelve years old, residing in Erie County, N. Y., was 
brought to me six weeks after the accident had occurred. The surgeon 
who was first called declared it to be a dislocation, and told the parents 
he had reduced it; but the dislocation was now complete, and the arm 
immovably fixed in its abnormal position. 

On the 10th of May, 1850, J. P., of Canada West, set. 25, was thrown 
from a load of hay, striking upon his left hand, and producing a dislo- 
cation backwards of both bones at the elbow-joint. A Canadian surgeon, 
who saw the patient within three hours, recognized the dislocation, and by 
pulling the arm straight forwards he supposed he had reduced it ; the 
patient also thought he felt the bones slip into place. No attempt was 
made subsequently to flex the arm, and it was immediately dressed with 



DISLOCATION OF RADIUS AND ULNA BACKWARDS. 691 

a straight splint laid along the palmar surface. On the sixth day it was 
found to be unreduced, and the surgeon again attempted to reduce it as 
before, and thought he had succeeded. The same splint was reapplied. At 
about the end of six weeks three surgeons, residing in Canada also, placed 
the patient under the complete influence of chloroform, and attempted 
the reduction. They first made extension for half an hour in a straight 
line, then five men seized upon the arm and forearm, bending it with great 
force to a right angle. It was now believed that the ulna was reduced, 
but not the radius. Four days after, the attempt was renewed. Three 
months after the accident the young man called upon me, and I found the 
arm nearly straight, with almost complete anchylosis at the elbow-joint. 
Both the radius and ulna were displaced backwards, but not upwards. 
The arm was of the same length with the other, and the relation of the 
condyles to the olecranon was so manifest, that the absence of the usual 
displacement upwards was easily determined. I was unwilling to make 
any further attempts at reduction, not believing that I should succeed 
after so much time had elapsed, and after so many ineffectual attempts 
had been made by clever surgeons. 

In the following examples the dislocation was supposed to have been 
a fracture of the lower end of the humerus. 

A man, residing in Pittsfield, Mass., dislocated his left arm by falling 
from a horse. The surgeon who was called regarded it as a fracture at 
the base of the condyles, and treated it accordingly. Ten weeks after, 
the error was discovered and an attempt was made to reduce it, but 
without success. A second attempt was also made, with the same result. 

The patient was brought to me eight months after the accident, with 
the bones still unreduced. The forearm hung at a very obtuse angle 
with the arm, and there was very slight motion at the elbow-joint. I 
discouraged any further attempts at reduction. 

Mr. W., of Alleghany Co., N. Y., set. 43, fell from a load of hay, 
striking upon his left arm, Feb. 16, 1853. Four hours after, he was 
seen by a young but very intelligent surgeon, who thought the humerus 
was broken just above the condyles. After eight weeks, the fact that 
it was a dislocation having become apparent, three surgeons, well known 
to me as men of large experience, attempted its reduction aided by pul- 
leys and chloroform. The patient was also bled, and nauseated with 
antimony. The efforts were protracted through many hours, and fre- 
quently varied. A second attempt made by these same gentlemen, a few 
days after, was equally unsuccessful. 

*On the ninth week Mr. W. came to me, and I placed him at once in 
the Buffalo Hospital of the Sisters of Charity, where, assisted by my 
friend Prof. Moore, of Rochester, I renewed the attempt at reduction. 
The patient was placed under the influence of chloroform, and during a 
great portion of the time occupied the pulleys were in use. The elbow 
was pulled upon, twisted, flexed, and extended, until there seemed to be 
neither adhesions, nor ligaments, nor capsule, to prevent the reduction. 
We could move the joint in every direction, even laterally, as well as for- 
wards and backwards. Still the bones would not return to their sockets. 
Section of the triceps seemed to be the only remaining expedient, but 
the injury already done to the joint was so great that we did not deem 



692 



DISLOCATIONS OF THE RADIUS AND ULNA 



it prudent to prosecute the attempt any further. We had occupied two 
hours in the various procedures. Violent inflammation supervened, but 
he was able to return home in about two weeks. Two years after, I 
learned that the. arm still remained unreduced, and nearly anchylosed ; 
the whole limb was also much atrophied and very weak. 

John Sharkie, set. 53, fell on the 4th of August, 1854. A botanic 
doctor, who saw him on the same day, and a regular physician, who saw 
him on the third day, thought he had broken his arm. About six weeks 
after this he came under the charge of an almshouse doctor, who " re- 
broke" it, supposing it to be a fracture ; and two months later he "broke" 
it again ; but as the arm was not improved by these operations, he finally 
urged upon the poor fellow to submit to amputation ; and it was in refer- 
ence to this last proposition that Sharkie consulted me. I found the 
radius and ulna dislocated backwards and upwards one inch ; the arm 
perfectly straight and the elbow anchylosed ; no pronation or supination. 
I did not think it prudent to make any attempt to reduce it, but assured 
him that if let alone it would ultimately be quite useful in many ways, 
and that he should never think of having it cut off. 

In at least eleven additional cases, according to my records, the acci- 
dent has been overlooked by reputable surgeons ; the injury having been 

supposed to be either fracture or a 
Fig. 282. mere contusion. Two of these had 

been examined by house surgeons at 
Bellevue. In one other case my house 
surgeon supposed he had reduced the 
dislocation, when he had not. 

In three or four instances, also, the 
accident has been overlooked by the pa- 
tient himself, or by some empiric, no 
surgeon having been called to see the 
case until after the lapse of several 
days or weeks. 

In general, when the reduction has 
been effected promptly, the patients 
have recovered the complete use of the 
elbow-joint within a few weeks ; but 
many exceptions have from time to time 
come under my notice'. 

A lad eight years old was brought 
to me, whose arm had been dislocated 
six months before, and the reduction 
of which had been accomplished easily 
and promptly by Sir Astley Cooper's 
method. At this time the arm was 
bent to a right angle, and quite stiff at 
the elbow-joint. Four years later I 
continued in a great measure, with only 




Reduction -with the knee in the "bend of the 
elbow. 



learned that the stiffness 
slight improvement. 



still 



Treatment. — Sir Astley Cooper thus describes his own method of re- 
ducing this dislocation : " The patient is made to sit upon a chair, and 



DISLOCATION OF RADIUS AND ULNA BACKWARDS. 693 

the surgeon, placing his knee on the inner side of the elbow-joint, in the 
bend of the arm, takes hold of the patient's wrist, and bends the arm. 
At the same time he presses on the radius and ulna with his knee, so as to 
separate them from the os humeri, and thus the coronoid process is thrown 
from the posterior fossa of the humerus ; and whilst this pressure is sup- 
ported by the knee, the arm is to be forcibly but slowly bent, and the 
reduction is soon effected." - 

The same practice has been recommended by Erichsen, Gibson, Samuel 
Cooper, and others. The plan recommended by Dorsey is nearly identi- 
cal with that just described, only that, instead of the knee, he advises 
that the surgeon " interlock his fingers in front of the arm, just above 
the elbow, and draw it backwards." 

On the other hand, Liston and Miller recommend, as a better mode of 
procedure, that the patient shall be seated upon a chair, and that the 
arm and forearm shall be pulled directly backwards, so as to relax as 
completely as possible the triceps muscle, while counter-extension is made 
against the scapula. 

Skey says : " Extension of the forearm should be made from the hand 
or wrist in a straight direction downwards, as if for the purpose of simply 
elongating the arm." 

Pirrie prefers that an assistant shall grasp the forearm near its middle, 
instead of the wrist, and pull the arm straight forwards, while at the 
same moment the surgeon seizes upon the olecranon process with the 
fingers of one hand, and, placing the palm of the other against the front 
and upper part of the forearm, pulls forcibly backwards, so as to draw 
out the coronoid process from the olecranon fossa. Waterman recom- 
mends forced extension ; that is, bending the forearm forcibly back, as 
preliminary to flexion, with the view of lifting the coronoid process from 
the olecranon fossa. 1 

For myself, having generally practised the method recommended by 
Sir Astley, and having usually succeeded in the first attempt and with 
the employment of only moderate force, I confess that my predilections 
are in its favor ; yet I am not entirely certain but that an equal experi- 
ence with either of the other modes recommended might have changed 
these convictions. The truth is, I think, that in recent cases very little 
force is generally requisite to accomplish the reduction, and that it is 
not very material which of these several modes we adopt ; but in case 
of a failure by one mode, we ought immediately and without hesitation 
to resort to another, as the following case of failure by flexion will illus- 
trate : — 

A lad, set. 11, fell in a gymnasium from a height of six feet, striking 
probably upon his hand. I saw him within twenty minutes, and found 
the arm in the usual position. I attempted immediately to reduce it by 
Sir Astley 's method, but after a fair yet unsuccessful trial, I extended 
the forearm upon the arm until it was nearly straight, and then, with 
only moderate force, drew it promptly into place. 

If we still continue to encounter difficulties, the patient ought at once 

1 New Method of Reduction of the Elbow, by Thomas Waterman, M.D., Boston 
Med. and Surg. Journ., vol. iv. Nos. 12-13, new series, 1869. 



694 DISLOCATIONS OF THE RADIUS AND ULNA. 

to be placed under the influence of an anaesthetic, and, if necessary, the 
pulleys should be employed. 

When the reduction is accomplished, which is indicated generally by 
the sudden slipping of the bones and by the restoration of the natural 
form to the elbow-joint, the surgeon, in order to confirm his opinion, 
must flex the forearm upon the arm to a right angle. If the bones are 
in place, and there is not much swelling, this can generally be done 
without causing much, if any, pain; but if it cannot be done, this fact 
furnishes presumptive evidence that the reduction is not effected. In 
one instance, however, of recent luxation, this rule has not held good. 
A girl, get. 10, fell from a tree upon her hand. I was in attendance 
within half an hour, and found the usual signs characterizing this acci- 
dent. Reduction was accomplished readily by pulling at the hand mode- 
rately, with the forearm flexed, while my left hand pressed back the 
lower part of the humerus. After the reduction it was found impossible 
to flex the arm to a right angle without causing severe pain, and it 
became necessary, after placing it in a sling, to allow the hand to drop 
very low beside the body. A. good deal of inflammation followed ; but 
in a few weeks the arm was well, only that for a period of two years or 
more the elbow remained very tender. 

On the other hand, an omission to apply this rule has often led the 
surgeon to believe the reduction accomplished when it was not. This 
same thing has happened to myself, and as it is the only instance in 
which I have omitted to adopt this test, and the only one also in which 
I have left a bone unreduced which I believed to have been reduced, it 
will be proper to state the case and its results more fully. 

A lad, aet. 11, fell from a fence on the 22d of December, 1858, and 
dislocated both bones backwards. I saw him within two hours from the 
occurrence of the accident. The elbow was already considerably swollen 
and quite tender, but the signs of dislocation were very manifest. Seizing 
the wrist with one hand, and placing my knee against the front and lower 
part of the humerus, I pulled steadily for some time, and with much 
more force than is usually necessary, until at length two distinct and 
successive snaps were felt, such as one often feels when the two bones 
resume their sockets. Relinquishing my grasp, it was observed by 
myself and the parents that the deformity had disappeared. The reduc- 
tion seemed to be complete, and so I announced. I then requested the 
lad to permit me to bend the elbow, and place it in a sling, but this he 
peremptorily refused to do, and ran away from me, nor would any argu- 
ments or entreaties persuade him to allow me again to touch it. I re- 
assured the parents and child, however, that all was right, and left the 
house. During several successive days I saw the little patient, but 
although the arm remained swollen and very tender, I did not suspect 
the cause until the ninth day ; and on the tenth day, having placed him 
under the influence of chloroform, the reduction was easily and satis- 
factorily accomplished. The recovery has been slow. At the end of 
six weeks I found the motions of the elbow-joint not completely restored, 
and the forefinger was partially paralyzed; but from this condition it 
has gradually recovered, and two months later the functions of the arm 
and hand were completely restored. 



DISLOCATION OF RADIUS AND ULNA BACKWARDS. 695 

The mistake in this instance was the more mortifying because I had 
just seen a case in a lad only a little older, in which another surgeon 
had committed the same error, and after the lapse of twelve or fourteen 
days I had myself made the reduction; and I was fully awake, therefore, 
to the possibility of the mistake. 

The circumstance of the diminution and apparent disappearance of 
the deformity, and the sensation of a double click, can only be explained 
by assuming that originally the coronoid process was resting in the 
olecranon fossa, and that by manipulation the bones had been removed 
nearer their sockets, yet not actually reduced. The swelling, also, 
rendered more difficult a diagnosis which, now, nothing but the flexion 
of the forearm could have determined positively. 

If much time has elapsed since the occurrence of the dislocation, the 
reduction is accomplished with difficulty, if indeed, it can be reduced at 
all. There are many cases upon record, however, in which surgeons 
have been successful after the lapse of many weeks, or even months. 
Boyer thought it was not possible to effect the reduction after four or 
six weeks; but Capelletti, of Trieste, succeeded after seventy days; 1 
Sir Astley Cooper, at three months; 2 Malgaigne, after three months and 
twenty-one days. 3 Roux succeeded in a case of a young man twenty- 
two years of age, whose elbow had been dislocated five months. 4 Black- 
man, of Cincinnati, informs me that he has reduced a lateral luxation 
after five months. Brainard, of Chicago, reduced a dislocated elbow 
in a boy of nineteen years, after five months and thirteen days. In 
this case the surgeon who had first seen the patient supposed that he had 
reduced the dislocation. 5 Gorre, Gerdy, and Drake succeeded in four 
cases after six months ; 6 I have succeeded at seven months ; and Starch 
claims to have been successful after two years and one month. 7 To 
which enumeration Denuce has added seventeen other examples said to 
have been reduced at various periods, ranging from one month to one 
hundred and fourteen days. 8 

I have reduced quite a number of these old luxations, the last five of 
which will be briefly recorded. 

Thomas Robertson, set. 35, was admitted to Bellevue Hospital, De- 
cember 14, 1864, with a simple dislocation of the radius and ulna 
backwards, which had existed thirty-one days, but w T hich had not been 
up to this moment recognized by his surgeon. I reduced it before the 
class, by Sir Astley's method, the patient being under the influence of 
ether. Considerable force was required. 

J. G., set. 7, was brought to me in November, 1865, with a backward 
dislocation of the right radius and ulna, which had existed nine weeks. 
The arm was nearly straight and fixed. Having placed him under the 
influence of ether, assisted by Dr. Gurdon Buck, of this city, I pro- 

1 Capelletti, Am. Journ. Med., vol. xix. from Annal. Univ. de Med. for Oct. 1835. 

2 Sir Astley Cooper, On Dislocations and Fractures, Amer ed., p. 388. 

3 Malgaigne, Amer. Jonrn. Med. Sci., vol. xxiii. p. 238, from Revue Med., Dec. 1837. 

4 Roux, Amer. Journ. Med Sci., vol. xvi. p. 526, from Archives Gen., Dec. 1834. 

5 Brainard, Illinois and Indiana Med. Journ., 1847. 

6 Memoire sur les luxations de coude, par Paul Denuce, Paris, 1854, pp. 86, 87. 

7 Denuce, op. cit., p. 87. 8 Op. cit. 



696 DISLOCATIONS OF THE RADIUS AND ULNA. 

ceeded to flex the arm slowly, and after a few seconds, and when the 
elbow was bent about ten or fifteen degrees, the olecranon process sepa- 
rated at the line of epiphyseal union. In a few moments the reduction 
was completed, and the arm brought to an acute angle, but the olecranon 
had separated full half an inch. We were quite certain that the ulna 
was perfectly reduced, but the head of the radius did not seem to 
occupy its original position fully. Only moderate inflammation ensued. 
Passive motion was soon commenced, and considerable motion of the 
joint was finally obtained. 

In April, 1869, a gentleman, set. 30, consulted me on account of a 
dislocation which had then existed ten weeks, and which had not been 
recognized by his surgeon. In attempting to reduce the dislocation 
I fractured the olecranon, and brought the ulna into position , but I 
could not reduce the radius. Almost complete anchylosis of the elbow 
remains. 

In 1870, a man was brought to me whose elbow had been dislocated 
eight weeks. Under ether, I succeeded in reducing the dislocation, but 
fractured the olecranon process in doing so. He has recovered very good 
use of the joint. 

October 22, 1869, before the class of medical students at Bellevue, I 
reduced a dislocation in the case of a woman set. 37, which had existed 
since the 10th of the preceding March, a little more than seven months. 
I have seen her often since ; she has a somewhat limited but very useful 
motion of the joint. 

A few years since I assisted Dr. Sayre in reducing an old backward 
dislocation of these bones in the case of a boy. Other means having 
failed, while Dr. Sayre forcibly flexed the arm, I cut the triceps, after 
which the reduction was easily effected. Some months later the arm was 
nearly anchylosed at the elbow-joint, and it did not promise very well, 
so far as the usefulness of the member was concerned. 

Dr. W. F. Westmoreland, of Atlanta, Ga., has reported a case in 
which he succeeded readily in reducing a dislocation of the elbow back- 
wards, of five months' standing, in a woman aged 22 years. The reduc- 
tion was followed by great pain, a good deal of swelling, temporary 
impairment of circulation in the radial artery, complete paralysis of the 
little finger, and partial paralysis of the middle and ring fingers. On 
the fourteenth day, at which period the history of the case closes, all 
these symptoms were rapidly disappearing. 1 

Nevertheless, the fact is in the main as stated by Boyer ; and if so 
many cases can be found in which surgeons have succeeded at a late 
period, they are not probably in the proportion of one to five as com- 
pared with the failures : but the failures have not received the same 
publicity. Nor, indeed, have all the severe accidents, such as violent 
inflammation, suppuration, gangrene, and even death, been faithfully de- 
clared. Denuce says he has been able to trace out five or six examples 
in which, although the arm was reduced, grave accidents resulted, and 
Velpeau's patient actually died in consequence. 

Michaux, at the Hopital de Louvain, in 1841, in reducing an elbow 

1 Westmoreland, Atlanta Med. and Surg. Journ., May, 1866. 



DISLOCATIONS OF RADIUS AND ULNA OUTWARDS. 697 

dislocation, tore off the median nerve and brachial artery. Amputation 
was made, and the life of the patient saved. 1 

Dixi Crosby, of New Hampshire, has treated two cases of ancient dis- 
location of the forearm backwards, by bending the elbow forcibly so as 
to break the olecranon process, after which the reduction was easily 
accomplished by extension. R. D. Mussey, of Cincinnati, has succeeded 
once in the same manner. 2 I have reported three similar examples. 
Malgaigne says that Cappelletti published an example in 1835, and that 
Morel-Lavallee, Roux, and Maissoneuve had each met with the accident. 3 

The dislocation being reduced, it may be a matter of prudence, some- 
times, to apply a right-angled splint, first carefully padded, to the palmar 
surface of the arm and forearm ; remembering, however, that consider- 
able swelling will soon occur, and that it ought not therefore to be band- 
aged to the limb very tightly. At least once a day it should be removed, 
and the arm examined ; and in very few cases can it be necessary or 
judicious to continue its application beyond one week. At the same time, 
if there is any especial tendency in the radius to become displaced back- 
wards, owing to a rupture of its annular ligament, this must be prevented, 
if possible, by a compress and bandage. Some surgeons regard these 
precautions as necessary in all cases, but I have seldom employed any 
splint or bandage whatever, nor have I ever had reason to regret this 
omission. 

Finally, we are to place the arm in a sling, and adopt such measures as are 
calculated at first to reduce the inflammation ; and at a very early day we 
ought to begin to move the elbow-joint, in order to prevent anchylosis. 

Dislocations Backwards and to the Radial Side will be considered in 
connection with outward dislocations ; and Dislocations Backwards and 
to the Ulnar Side, in connection with dislocations inwards. 

§ 2. Dislocations of the Radius and Ulna Outwards (to the Radial Side). 

a. Complete Dislocations. — The large majority of outward dislocations 
of the forearm are incomplete ; indeed, only nine examples of a complete 
dislocation have been collected by Denuce, including two seen by himself. 4 
Malgaigne has since added two more ; 5 Moliere, of Lyons, has reported one, 6 
Andre ws one, 7 Osborne one, 8 Varick one, 9 Wylie one, 10 Dr. Erskine Mason 
has reported two, in children of seven and twelve years respectively, and 
he refers to another reported by one of his colleagues at Bellevue in the 
Medical Record for Oct. 9, 1875, in the person of a lad set. 17, 11 making 
in all nineteen cases. Dr. Varick's case is reported as follows : — 

1 Debruyn, Des Luxations du Coude. These Inaug., Louvain, 1843, p. 77. 

2 Crosby, Mussey, Trans. Amer. Med. Assoc, vol. iii. p. 357. 

3 Malgaigne, op. cit., Paris ed., 1855, vol. ii. p. 144. 

4 Denuce, Mem. sur Lux. des Coudes. Paris, 1854. 

5 Malgaigne, op. cit. 

6 Moliere, Monthly Abstract Med. Sci., vol. i., 1874, p. 269. 

7 Andrews, Med. Record, Oct. 23, 1875, p. 720. 

8 H B. Osborne, Hosp. Gazette, Nov. 29, 1879, p. 613. 

9 T. R. Varick, Mel. Record, Nov. 1, 1867, p. 387. 

10 W. Wylie, Med. and Surg. Rep., March 22, 1879, p. 250. 

11 Mason, Med. Record, April 10, 1880, p. 397. 

45 



^ r :si : :at: : >-5 :•? thi ?.a::t= a>" v :" . 

e :*rge Knight, set. - thrown violendy from a wagon while 

in rapid motion, striking on his head and back, with his left arm behind 
him in a state of flexion. He was brought to my office on the 31st of 
Auj * ~ . iihin ten minutes after the receipt of the injury, and. 

consequently, in the most favorable condition for manipulation, no swell- 
ing of the soft parts having yet occurred. The forearm was in a state 
of semiflexion, supported by the hand of die opposite side, the ulna lying 
to the outer side of the external condyle, with slight posterior projection 
of the olecranon. The olecranon, coronoid process, and greater sigmoid 
cavity could be distinctly defined, and the head of die radius, in its 
normal relations to the ulna, could be felt rotating suheutaneouslT on 

every direction was present, giving the impression of being attached to 
the arm solely by the soft parts. The projection of the internal condyle 
was out of all proportion to what is seen in cases of incomplete luxation. 
The trochlea, coronoid depression, and the olecranon depression were 
distincdy recognized. Complete dislocation of the ulna outwards was 
diagnosed, which diagnosis was corroborated by my friend. Dr. E. A. 
(son, who was present and assisted in the reduction. 

be patient was placed fully under the influence of ether, and 
moderate extension, combined with lateral pressure, effected die reduc- 
tion without difficulty. The subsequent treatment consisted of rest and 
cold irrigation for a few days, followed by passive motion of the parts, 
which resulted in perfect recovery. The amount of inflammation which 
followed the injury was exceedingly slight- due unquestionably to the 
prompt reduction of the luxation/* 

Wylie kindly permitted me to see the case which he has reported. 
and of which the two accompanying wood-en: ~ .- . _ - - ~ _ - . are 

: 



excellent illustrations. I . who was at that time House-Surgeon 

at the Long Island College Hospital. Brooklyn, in the service of D: B 

ird Baker, aged thirty-eight, native of St. John's. Newfoundland, 
was engaged in a fishing enterprise in 1862. While fishing, standing 



DISLOCATIONS OF RADIUS AND ULNA OUTWARDS. 

on a staging, formed of three-inch sticks, laid crosswise, three inches 
apart, he fell, with one arm raised, striking on the inner side of the elbow : 
at the same moment a barrel of fish, weighing two hundred and fiftv 
pounds, fell over, striking the arm about three inches above the external 
condyle. Upon rising be found the arm flexed at a right angle, pro- 
nated, and immovable at the elbow-joint. No attempt at reduction was 
ever made, nor was there any retentive apparatus applied. He put the 
arm in a sling, and after a couple of months he commenced using it a 
little. At the end of two years his arm was sufficiently recovered to 
permit him to return to his sailor life, which be followed up to six months 
_ . when he was admitted to the Long Island College Hospital, for 
other injuries. 

At the present time, seventeen years after the accident, the inner 
border of the olecranon process rests upon the external border 
humerus, above the external condyle. . probably, an articular 

284. 




The same. Arm nearlv extended ; the lev- - 

facet has been developed. Just anterior to and to the inner side of 
this is the head of the radius, which can be recognize.' I y sight, but 
more surely identified by touch. The internal condyle of the humerus 
projects greatly, and the trochlea can be distinctly felt. When ex- 
tended, the radial border presents a gentle outward inclination from the 
elbow down. This may be greatly increased or diminished by manipu- 
lation. This extremity is one and three-quart - :: inch shorter than 
the other. (^This is my own measurement, and differs a little from that 
given by Dr. Wylie.) * The patient has full control of this limb, can flex 
or extend, pronate or supinate it nearly as well as the other, and he 
thinks it is in every particular as serviceable as the other. 

b. Incomplete Dislocations, — Incomplete dislocations must, however, 
in this case be regarded a- typical; but even these are by no means 
frequent. 

Causes of Incomplete Outward Dislocations. — A careful examination 
of a large number of recorded examples, and of those which have come 
under my own eye. renders it certain that rity )f these 

result from a blow received directly upon the inner 'side of the forearm 
or upon the outer side of the humerus, or from the action of two forces 
pressing in an opposite direction. Of course, these forces must act 
upon the bones somewhere in the neighborhood of the elbow-joint, 
casionally it has been produced by a fall upon the hand : sometimes by 



TOO 



DISLOCATIONS OF THE RADIUS AND ULNA. 



Fig. 285. 




a violent twist of the arm, as when the hand is caught in machinery ; 
and in other cases it has been found consecutive upon a dislocation 
backwards, being produced in the attempts made to 
accomplish reduction of this latter form of disloca- 
tion. 

Pathology. — In most of the examples of simple 
incomplete outward luxation of the forearm, the 
great sigmoid cavity of the ulna still embraces the 
lower end of the humerus ; but instead of reposing 
upon the trochlea fairly, it is carried outwards half 
an inch or more, so as to rest its central crest upon 
the depression which separates the trochlea from the 
lesser or radial head of the humerus. If the annu- 
lar ligament remains unbroken, the radius is dis- 
placed in the same direction and to the same extent. 
Occasionally, however, where the violence has 
been greater, the central crest of the great sigmoid 
cavity rests fairly upon the condyle, or upon the 
articulating surface of the humerus where the head 
of the radius was formerly applied, and the disloca- 
tion approaches more nearly to the character of a 
complete luxation. At the same time, owing per- 
haps to the resistance afforded by the skin, or some 
of the ligaments, the head of the radius may be 
thrown either forwards or backwards, so as to be 
out of line with the ulna. Such a displacement 
generally implies a rupture of the annular ligament. 
We have now only to suppose the action of a more considerable force 
in the same direction to render the dislocation complete ; in which case 
the upper end of the radius is sometimes thrown completely forwards, 
and its head may even be found resting in front of the ulna, occasioning 
an extreme pronation of the forearm and hand. 

The anconeus and brachialis anticus are the only muscles in either of 
these dislocations whose fibres are generally much disturbed ; the biceps 
and triceps being only made to traverse the articulation a little more 
obliquely. 

Denuc6, Malgaigne, A. Cooper, and others have preferred to speak of 
the dislocation backwards and outwards as a distinct form or species of 
dislocation. I prefer to regard it as only a variety of the outward 
luxation, since it may, and no doubt often does, occur consecutively upon 
a simple incomplete outward dislocation ; and if the dislocation outward 
is complete, the benes of the forearm can scarcely fail to be drawn more 
or less upwards. Sometimes also it has been consecutive upon a simple 
backward dislocation, or upon unsuccessful attempts at reduction where 
the form of dislocation was originally backwards ; yet, as it does not 
so naturally follow upon a complete backward dislocation as upon a com- 
plete outward luxation, I find sufficient reason for studying its mechanism 
in this place. 

The beak of the olecranon process not only, but a large portion of the 
body of this process, now lies above and behind the condyle ; the 



Most frequent form of 
incomplete outward dis- 
location of the forearm. 



DISLOCATIONS OF RADIUS AND ULNA OUTWARDS. 701 

brachialis anticus becomes more stretched, if not actually torn ; and the 
biceps is laid against the articulating surface of the humerus ; but the 
triceps becomes again relaxed, as in simple dislocation backwards and 
upwards. 

In all these dislocations the capsular ligaments are more or less exten- 
sively torn, but the principal arteries and nerves do not generally suffer 
greatly, if at all. 

Symptoms of Incomplete Outivard Dislocation. — The forearm is usually 
flexed to about the same angle at which we have found it in dislocations 
backwards ; once I have found it nearly or quite straight ; occasionally 
it is flexed to a right angle. In all the cases seen by me the forearm 
has been pronated, and the elbow-joint has been very immovable. The 
most striking diagnostic sign, however, consists in the unnatural form of 
the elbow-joint, which is so remarkable as not to be easily misunder- 
stood. The internal condyle of the humerus (epitrochlea) projects 
strongly to the inner side, leaving a deep depression below ; while upon 
the other side, the head of the radius, with its cup-like extremity, can 
be distinctly felt, and made to rotate outside of its socket. The olecra- 
non process, driven from its fossa, projects more or less posteriorly, and 
even the fossa itself may sometimes be plainly felt. 

A girl, twelve years old, had fallen upon the inside of her elbow, pro- 
ducing an incomplete dislocation outwards of the forearm. I saw her 
within half an hour. The forearm was bent upon the arm about fifteen de- 
grees, and immovably fixed. The head of the radius could be distinctly 
felt external to and a little in front of the outer condyle, while the ole- 
cranon process of the ulna, which rested upon the back and outer surface 
of the humerus, was less distinctly felt than in the opposite arm. The 
inner condyle projected sharply to the inside, and the olecranon fossa 
was plainly felt with the fingers. The child was suffering very little 
pain. 

Seizing the wrist with my right hand and the lower end of the humerus 
with the left, and making moderate extension in these opposite directions, 
the bones easily, and after only a moment's effort, resumed their places. 
Her recovery was rapid and complete. 

James O'Neil, set. 16, was admitted to Bellevue Hospital in Dec. 1865, 
with a partial dislocation caused by the kick of a horse, the blow having 
been received on the ulnar side of the forearm near the elbow-joint. 
When he came under my notice the dislocation had existed three weeks. 
I found the head of the radius reposing upon the radial and posterior side 
of the humerus. The ulna was displaced one inch to the radial side. 
The forearm was not at all, or but very slightly, flexed upon the arm. 
The natural deflection of the forearm to the radial side was a* little ex- 
aggerated: forearm pronated: elbow-joint admitting of a little motion; 
but motion caused great pain. 

This patient was not in my service, and I have not learned the result 
of the attempt at reduction. 

If the dislocation is complete, the position of the arm is usually the 
same, but the pronation of the hand is greater, and the projection of the 
inner condyle more striking. 

If now the bones, by a continuance of the original force, or by the 



702 DISLOCATIONS OF THE RADIUS AND ULNA. 

action of the triceps, are drawn upwards also, the arm becomes a little 
more flexed, and the olecranon process more prominent, while the length 
of the whole limb is sensibly diminished. 

Prognosis in Incomplete Outward Dislocations. — In recent cases, and 
where no complications exist, the reduction is generally easily effected ; 
and M. Thierry claims to have reduced an outward and backward semi- 
luxation after eight months. A patient of whom Debruyn has spoken was 
not so fortunate. On the 16th of April, 1841, a lad, set. 18, fell upon the 
palm of his hand and semi-luxated both bones outwards and backwards; 
on the following morning a surgeon attempted to reduce the dislocation, 
and the attempt was repeated on the next day by another surgeon ; but 
on the day following this last attempt, gangrene ensued in consequence 
of the great violence employed by the surgeons, and although the limb 
was amputated, the patient died. The autopsy showed that both the 
brachial artery and the median nerve were torn asunder, and that the 
tendons of the biceps and the brachialis anticus were slipped behind the 
outer condyle, probably having been thrown into this position during the 
violent twistings to which the arm had been subjected. 1 

I have seen three examples of semi-luxations upwards and outwards 
which the medical attendants had failed to reduce. The first was in the 
case of a lad, William Kinkaid, fourteen years old, who had fallen from 
a wagon and struck upon the palm of his left hand. The surgeon who 
was immediately called made extension, and supposed that the reduction 
was accomplished. The lad was brought to me a few months after the 
accident. The arm was slightly flexed, and neither prone nor supine. 
There existed only a slight motion at the elbow-joint. I did not think it 
worth while to make any attempt at reduction. Several years after this, 
in the month of February, 1859, I had an opportunity of examining the 
arm again. He had now recovered considerable motion in the joint, but 
he could not tie his cravat. Pronation and supination were perfect. 

In the second example, a lady, set. 33, had fallen upon the inside of 
her elbow, and reduction not having been accomplished, I found her, nine 
weeks after the accident, with scarcely any motion at the elbow-joint, and 
complaining of a numbness in the forearm and hand. 

The third instance of unreduced semi-luxation I will relate more at 
length. 

Francis Banfield, aged twenty-two years, a resident of Alleghany 
County, N. Y., on the 31st of September, 1857, fell from the sweep of 
a threshing-machine to the ground, a distance of about five feet, striking 
upon the palm of his hand, his arm being extended in front of him. On 
rising, he found his arm forcibly flexed and abducted. He straightened 
it without difficulty, and it assumed the position it now occupies. A 
physician was called and saw the patient an hour and a half after the 
accident, who pronounced it a case of dislocation of the radius and ulna, 
and made efforts at reduction, which he continued from 8J A. M. until 2 
p. M., a period of five and a half hours, to no purpose, when he aban- 
doned the attempt. During the attempt at reduction, the extension was 
made at times with the arm flexed, and at others extended. At 9 p. m. 

1 Denuce, op. cit., p. 103. 



DISLOCATIONS OF RADIUS AND ULNA OUTWARDS. 703 

another physician was called, who made efforts at reduction until 3 A. M., 
upwards of six hours, at which time he also abandoned the attempt. On 
the third day another physician, the patient being under the influence 
of ether, made efforts at reduction for twenty minutes, when he pro- 
nounced it in place, and applied a bandage. From the patient's account, 
the arm was swollen to such an extent as to render this point difficult to 
determine. On the fifth day the first physician was called, and, believing 
that he discovered a grating, pronounced it a fracture of the external 
condyle. 

Four months after the accident, when the patient applied to me, the 
limb presented the following appearances : The "forearm extended upon 
the arm ; looking at the limb along its radial margin, we notice a gentle 
outward inclination of the forearm from the elbow down, but by manipu- 
lation this may be greatly increased ; the power of pronation and supina- 
nation is not affected ; the inner condyle projects an inch to the ulnar 
side ; the head of the radius, completely removed from its socket, projects 
to an equal extent on the radial side. The top of the olecranon process 
is an inch higher than the top of the inner condyle, so that the radius 
and ulna are carried upwards as w T ell as outwards." 

I believe that the external condyle was not broken, as in that case the 
arm would be permanently deflected outwards to a much greater extent. 
For, although this arm may be deflected outw r ards by the surgeon to an 
angle of 135°, still the degree of mobility which exists would be adverse 
to the supposition of its being a fracture of the external condyle. The 
condyles also can be plainly felt in their natural situations, which would 
not be the case if a fracture of the external condyle existed. The 
patient was advised not to submit to any further attempts at reduction. 

The following will serve as an illustration of a recent accident of this 
character: — 

John Collins, of Buffalo, aet. 8, fell while wrestling, his companion 
falling upon his arm. I found the forearm slightly flexed, pronated, and 
both radius and ulna thrown over to the radial side and carried upwards. 
Pressing firmly upon the radius from the outside, the bones assumed 
suddenly the position of a backward and upward dislocation, from which 
position they were readily reduced to their original sockets by simple 
extension. 

Treatment of Incomplete Outward Luxations. — In relation to the 
treatment of these accidents we have little to add to what has already 
been said of the treatment of dislocations backwards. The reduction, if 
effected at all, has generally been accomplished by moderate extension, 
or by extension combined with lateral pressure. If the head of the 
radius is in front of the humerus, or of the ulna, the hand should be 
first supined, and then the extension should be applied. In some cases 
the reduction has been effected by placing the knee in the bend of the 
elbow and flexing the forearm, while the surgeon was making extension 
from the hand. 



704 



DISLOCATIONS OF THE RADIUS AND ULNA 



Fig. 286. 



§ 3. Dislocation of the Radius and Ulna Inwards (to the Ulnar Side), 
always Incomplete. 

This form of dislocation is much more rare than the dislocation out- 
wards, a fact which may perhaps find a sufficient explanation in the 
peculiar form of the trochlea, the inner half of which rises much higher 
than the outer, forming thus an elevated inclined plane, over which the 
articulating surface of the ulna must rise before the dislocation can 
occur. 

Like the opposite dislocation, the typical form of the accident is that 
in which the displacement is incomplete ; indeed, no example of a com- 
plete inward dislocation lias, we think, been yet recorded. 

Causes. — A fall upon the hand or forearm, a blow upon the radial 
side of the forearm near its upper end, or upon the ulnar side of the arm 
near its lower end, a violent wrenching of the limb, are among the causes 
which may occasion this dislocation. 

Pathology. — The ridge which divides antero-posteriorly the greater 
sigmoid cavity of the ulna, having been driven over the elevated inner 
margin of the trochlea, falls down upon the epitrochlea, so as, in some 
sense, to embrace it instead of the trochlea; while the head of the 
radius passes inwards also, and is made to occupy the trochlea, from 
which the ulna has escaped. Generally the head of the radius is found 
in the same line with the ulna (Fig. 286), but 
it may suffer a luxation and be found a little in 
advance of the ulna, or possibly a little back of 
the ulna. 

I choose also to regard the semi-dislocation in- 
wards and upwards as only a variety of the semi- 
dislocation inwards ; in which form of the acci- 
dent the coronoid process of the ulna is thrust 
upwards above the epicondyle, and the head of 
the radius occupies the olecranon fossa, or rests 
upon the back of the humerus somewhere in this 
vicinity. 

In addition to the injury suffered by the liga- 
ments and muscles, the ulnar nerve in both 
varieties of inward dislocation is peculiarly 
liable to contusion, in consequence of its being 
crushed between the olecranon process and the 
epitrochlea. 

Symptoms. — If the displacement is only in- 
wards, the olecranon process can be felt pro- 
jecting upon the inner side, and completely 
concealing the epicondyle ; while the head of 
the radius, having abandoned its socket, may 
be felt indistinctly in the bend of the arm. 
The external condyle (epicondyle) is remark- 
ably prominent. The forearm is generally more or less flexed. The 
natural outward deflection of the forearm is also lost, or it may be even 
inclined slightly inwards. 




Most frequent form of incom 
plete inward dislocation of th< 
forearm. 



This phenomenon is explained by the position 



DISLOCATION OF RADIUS AND ULNA INWARDS. 705 

of the epicondyle, upon which the greater sigmoid cavity now rests, 
allowing the ulna to overlap a little upon the humerus ; rendering the 
forearm actually somewhat shorter along its ulnar margin, although the 
head of the radius may still occupy the summit of the trochlea. 

If the bones are displaced upwards, as well as inwards, a consider- 
able shortening is declared, and the head of the radius may now be felt 
behind the trochlea, or over the olecranon fossa. In three of the four 
examples seen by Malgaigne, all of them ancient, the forearm was in a 
state of supination. 

August 25th, a girl, set. 5, fell from a swing, striking upon her right 
elbow. A physician was called, who supposed it to be a fracture. Five 
weeks later it was seen by Prof. T. F. Prewitt, of St. Louis, Mo. The 
forearm was flexed, and could not readily be extended beyond a right 
angle ; it occupied a position midway between pronation and supination 
ordinarily, but could be supinated and pronated perfectly. The olecra- 
non process was on a line with the extreme point of the inner epicondyle, 
and the head of the radius could be felt below the olecranon fossa. A 
finger could be pressed readily into the fossa. A small, sharp spiculum 
of bone had been torn off, and lay loose over the external condyle, which 
was very prominent. Attempts were made by Dr. Prewitt to reduce the 
dislocation under the influence of an anaesthetic, but without success. 1 

The following example of this dislocation, unreduced after the lapse 
of fourteen years, is reported to me by Dr. T. H. Squier, of Elmira, N. 
Y. : Thomas Cook, now in his nineteenth year, was four years and ten 
months old when he fell from a pile of boards about as high as a man's 
shoulder. According to his statement, given at the time, his right arm 
caught between the boards, and, in falling, he turned a somersault. The 
mother, to whom the child immediately ran, grasped his arm which he 
said was broken, and found that it would roll and turn in various ways. 
When the surgeon arrived, three hours afterwards, the arm was very 
much swollen, and the accident was supposed to be a fracture. At pres- 
ent the flexion and extension are perfect. The forearm has an inward 
deflection of a hand's breadth more than the other. The power of pro- 
nation is complete, but the forearm and hand cannot be supinated entirely. 
The external condyle is very prominent, but the internal is almost hid by 
the olecranon, which projects inwards nearly as far as the point of the 
epicondyle. The finger can be laid in the olecranon fossa behind, and 
all the back part of the trochlea can be distinctly traced. By flexing 
the forearm slowly, as it approaches a right angle, the tendon of the tri- 
ceps may be felt, lodged, as it were, on the back part of the point of the 
epicondyle ; and by continuing the flexion, the tendon suddenly slips 
over this point and places itself on the anterior aspect of the arm. When 
the forearm is fully flexed, the tendon is advanced full three-quarters of 
an inch in front of the epicondyle. The arm is very serviceable, but 
invariably pains him after a hard day's work. 

Prognosis. — Malgaigne was unable to reduce the bones in a recent 
case of incomplete internal dislocation which came under his own 
notice. Triquet succeeded in a child seven years old, on the fifteenth 

1 Prewitt, St. Louis Courier of Med., Jan. 1879, p. 43. 



706 DISLOCATIONS OF THE RADIUS AND ULNA. 

day, after many trials ; but the movements of the elbow-joint were never 
restored. Dubruyn succeeded on the fifth day, but not without diffi- 
culty ; Prewitt failed at the end of five weeks ; the case reported by 
Squier was mistaken for a fracture, and no attempt at reduction was 
made ; and in a case seen by Velpeau, reduction was easily accomplished, 
and on the eighth day the patient was dismissed. 1 

Of the four examples of inward, backward, and upward luxation seen 
by Malgaigne, not one was ever reduced ; but as the history of them all 
is not complete, it is by no means to be inferred that the reduction could 
not have been easily accomplished, at least in some of them, at the first. 
Nor, with such imperfect details before us, can we understand fully what 
complications may have existed, such as would perhaps render these 
exceptional, rather than illustrative examples. 

One of these patients had a completely anchylosed elbow at the end of 
two years, but pronation and supination were preserved. In the case of 
another, however, even flexion and extension were as perfect as in the 
normal condition. 

Treatment. — The indications of treatment are the same as in semi- 
dislocations outwards, with only such slight modifications as the judg- 
ment of every surgeon must naturally suggest. I prefer to employ by 
way of illustration the example diagnosticated by Velpeau. 

On the 10th of May, 1848, Alexandrine Guyot, set. 22, entered the 
Hospital of La Charite' with an incomplete inward dislocation of the fore- 
arm, which had just occurred. The hand and forearm were in a state of 
forced pronation, half-flexed and the whole limb from the elbow down- 
wards was deflected inwards. There were present also all the other 
usual signs of this dislocation, and Velpeau had no doubt as to its true 
character. 

In order to accomplish reduction, one assistant made counter-extension 
upon the arm, while a second made direct extension upon the forearm. 
At first the tractions were made in the direction of the forearm (flexed 
and prone), but gradually the arm was straightened and supinated. 
Then the surgeon, seizing with one hand the superior extremity of the 
forearm, and with the other the inferior extremity of the arm, acted for- 
cibly upon the two portions in opposite directions, and immediately the 
reduction was effected with a noise. 2 

§ 4. Dislocation of the Radius and Ulna Forwards. 

Sir Astley Cooper, Vidal (de Cassis), and others have denied that this 
dislocation was possible without a fracture of the olecranon process ; but 
Monin, Prior, Velpeau, Canton, 3 and Denuce' have each reported one 
example, so that its existence may now be considered as established. 
Nevertheless, it is only as a result of very violent and extraordinary ac- 
cidents, by which the forearm is forcibly flexed, or greatly extended, or 
twisted, or in some other unusual and indirect way the olecranon is 
placed in front of the humerus. 

1 Denuce, op. cit., pp. 154-156. 2 Denuce^ op. cit., p. 155. 

3 Dub. Quart. Joum. of Med. Sei., Aug. 1860. 



DISLOCATION OF RADIUS AND ULNA FORWARDS. 707 

The following is a summary of the facts in Yelpeau's case. Alexan- 
drine Carelli, set. 23, was knocked down by a carriage, on the first of 
July, 1848, the wheel passing over the right arm. The arm was found 
in a right-angled position, and it could neither be flexed nor extended ; 

Fig. 287. 




E. Canton's case of dislocation of the radius and ulna forwards. 

the forearm was strongly supinated ; the projecting angle usually made 
by the olecranon process was replaced by the irregular extremity of the 
humerus; the forearm was shortened upon the arm; the head of the 
radius resting in the coronoid fossa, and the olecranon process being also 
carried upwards and a little outwards. Reduction was easily accom- 
plished, and the patient left on the nineteenth day, with only a slight 
remaining stiffness in the joint. 1 

A case is reported to have come under the observation of Mr. J. W. 
Langmore, house surgeon at the University College Hospital, London. 
It was occasioned by a fall upon the elbow. The reduction of the ulna 
was easily accomplished by placing the knee in the bend of the elbow 
and flexing the arm. The radius w r as then reduced by pressure and ex- 
tension. 2 

Chapel has reported a case of dislocation forwards and outwards, 
which he readily reduced soon after it occurred, while Colson, Leva, and 
Guyot have each reported one example of subluxation forwards, in which 
the extremity of the olecranon process has been found resting upon the 
extremity of the humeral trochlea. 3 

1 Denuce, op. cit., p. 110. 

2 New York Med. Record, March 1, 1867, from the London Lancet. 

3 Denuce, p. 120. 



708 DISLOCATIONS OF THE RADIUS AND ULNA. 

Treatment. — If the dislocation is complete, and the forearm is short- 
ened and flexed upon the arm, the reduction should first be attempted by 
violent flexion, or by flexion combined with extension from the wrist, and 
counter-extension from the lower portion of the humerus. If the dislo- 
cation is incomplete, and the forearm is extended upon the arm, the re- 
duction may be readily accomplished by extension alone, or by moderate 
flexion. 

§ 5. Dislocation of the Radius Forwards and Ulna Backwards. 

This accident was first recognized, according to Malgaigne, by M. 
Michaux and M. Bulley in 1841, when each of these gentlemen met with 
a case. 

Michaux's patient was a man, 44 years old, who had fallen eight feet, 
striking upon his elbow while it was carried away from his body. At 
first the dislocation of the radius was not recognized, but having reduced 
the ulna by traction, he discovered the head of the ulna in front, which 
was finally reduced by direct pressure made upon it with the thumb. 

M. Bulley's patient was a male also, aet. 28, who had been thrown 
violently upon the palm of his hand. The forearm was slightly flexed, 
and could not be moved from this position without causing great pain. 
The coronoid process rested in the olecranon fossa, and the head of the 
radius in the coronoid fossa. With slight traction the ulna was reduced, 
and afterwards the radius was reduced by methodic processes. 

M. Mayer reported a case which was not recognized until the four- 
teenth day, and then he found himself unable to reduce it. 1 

Denucd, in his " Memoire sur les luxations du Coude" (Paris, 1854), 
mentions these three cases and no others. 

To these cases, which are all I have found recorded to this date, I will 
add the case reported by Dr. Erskine Mason as having been seen by 
himself and Dr. Whybrew. The man was 28 years old, and the acci- 
dent had happened in a fall when he was intoxicated. He had supposed 
it was a sprain, and these gentlemen were not consulted until the eight- 
eenth day. The character of the dislocation was apparent, but they 
could not positively determine but that a portion of the external condyle 
had been broken off; there was, however, no crepitus. The limb was 
nearly straight, and would admit of but slight flexion. Under ether, 
prolonged efforts at reduction were made, with the result of finally re- 
ducing the ulna, but the radius remained unreduced. 2 

1 Michaux, Bulley, Mayer. From Malgaigne, Paris ed., 1855, vol. ii. p. 631. 

2 Mason and Whybrew, Med. Rec, April 10, 1880, p. 397. 



DISLOCATIONS OF THE WRIST. 709 



CHAPTEE X. 

DISLOCATIONS OF THE WRIST (RADIO-CARPAL). 

Regarded as an accident of not unusual occurrence by Hippocrates, 
J. L. Petit, Duverney, Boyer, and by most if not all of the older writers, 
its frequency began to be questioned by Pouteau, and finally its exist- 
ence was almost absolutely denied by Dupuytren, who remarks: "I have 
for a long time publicly taught that fractures of the carpal end of the 
radius are extremely common ; that I had always found these supposed 
dislocations of the wrist turn out to be fractures ; and that, in spite of 
all which has been said upon the subject, I have never met with, or heard 
of, one single well-authenticated and convincing case of the dislocation 
in question." Dupuytren subsequently declared that he would not posi- 
tively deny the possibility of the accident, yet that " it must at least be 
admitted that the accident is an extremely rare one." Wishing to explain 
this infrequency, he says: " In examining the structure of the soft parts, 
one cannot fail to perceive that it is not the ligaments which prevent the 
displacement of the articular surface forwards, but that this effect is es- 
pecially due to the multitude of flexor tendons, deprived as they are at 
this point of all the fleshy parts, and reduced to the simple fibrous tissue 
which composes them. These tendons are bound together beneath the 
anterior annular ligament of the wrist, and thus offer so efficient a re- 
sistance that severe falls are insufficient to tear them through ; the hand 
is forced into a state of extreme extension, and the tendons are firmly 
applied on the anterior part of the radio-carpal articulation. If the ex- 
tension is still further augmented, the wrist-joint is yet more closely 
clasped by these parts, and their power of resistance is incalculable ; I 
am convinced that a force equivalent to one thousand pounds weight 
would be inadequate to overcome it ; and the known power of the tendo 
Achillis is sufficient to prove that this computation is not exaggerated. 

" The risk of dislocation backwards by a fall on the dorsal surface of 
the hand is equally precluded by the tendons of the extensor muscles. 
Their arrangement and relations at the back of the joint are similar ; it 
is true, they are not quite so strong ; but we must admit that their power 
of resistance is very considerable, when we take into consideration how 
they are inclosed in sheaths as they cross beneath the posterior annular 
ligament of the wrist. I have not alluded to the ulna, for it has really 
little or nothing to do with these movements, as it does not articulate 
(directly) with the hand. 

" To sum up, then, the extreme rarity of dislocation forwards or 
backwards is owing to the obstacles opposed by the flexor or extensor 
tendons." 

The opinion of such a writer as Dupuytren, whose experience was very 



710 DISLOCATIONS OF THE WRIST. 

great, and who described only what he had seen, is always entitled to 
profound respect ; yet it has been the practice of nearly all who have 
made any reference to his opinions in this matter to speak of them lightly, 
and not a few have falsely represented him as saying that a dislocation 
was " impossible.'-' The fact is, that surgeons do still constantly mistake 
fractures of the lower end of the radius for dislocations, as my own per- 
sonal observations can attest ; and notwithstanding examples have been 
reported by Rene, Marjorlin, Padieu, Cruveilhier, Voillemier, Boinot, 
Malgaigne, Scoutetten, Bransby Cooper, Fergusson, W. Parker, and 
others, yet the whole number of cases for which the distinction is claimed 
is, to this day, so inconsiderable as only to establish the value and accu- 
racy of Dupuytren's opinion that the "accident is an extremely rare 
one." But it is, perhaps, most remarkable, that while very few of these 
supposed examples have been verified by an autopsy, in every instance 
in which the autopsy has been made, the dislocation has been found to 
be complicated with a fracture, generally of the lower extremity of the 
radius or of the styloid apophysis of the ulna. 

The existence of a complication, however, does not render the acci- 
dent any the less a dislocation, although it may render the diagnosis 
more difficult, and modify somewhat the indications of treatment. A 
knowledge of the fact, also, that such complications have always been 
observed in the autopsy, may leave us in doubt as to what is the nat- 
ural history of a simple uncomplicated dislocation, if, indeed, it does 
not warrant a suspicion that such a case never occurs. We shall, never- 
theless, after a careful analysis of the cases as they have been reported, 
and by a consideration of the anatomy of this articulation, be able to 
determine with some degree of accuracy, perhaps, what are, or what 
ought to be, the usual causes, signs, treatment, etc., of these accidents. 

Partial luxations have also been frequently described by surgeons. 
I have never met with an example, but the following case, related to me 
by the patient himself, I believe to have been a case in point. 

Lewis C, of Buffalo, set. 18, by a fall upon his hand, broke the left 
forearm below the middle, and at the same time, as he affirms, partially 
dislocated the carpal bones backwards. Dr. Spaulding, of Williams- 
ville, N. Y., took charge of the limb, and pronounced it a fracture, 
with partial dislocation, and for more than a year after the accident the 
bones had a tendency to become displaced in the same direction. When- 
ever he attempted to lift even the weight of half a pound, with his hand 
supinated and his forearm extended horizontally, the lower end of the 
radius would spring suddenly forwards, and all power in the arm would 
be lost. When this happened, as it did quite often, he always reduced 
the bones himself, by simply pushing upon them in the direction of the 
articulation. 

Fourteen years after the accident, I examined the arm and found it 
in all respects perfect, except that the forearm was shortened about one- 
third of an inch, which shortening was due, no doubt, to the overlapping 
of the broken bones. 

(I am unable to verify the accuracy of the statements made in the 
following paragraph; but as there seems to be no reason why they 



DISLOCATIONS OF THE CARPAL BONES BACKWARDS. 711 

should not be accepted, it will be proper to give them a place in this 
treatise. 

u According to Francis L. Parker, M.D., Professor of Anatomy in 
the Medical College of South Carolina (Trayis. S. C. Med. Assoc.'), 
there are thirty-three cases of so-called dislocations of the wrist-joint on 
record (omitting the cases of W. Parker and Bene), including his own, 
viz., case of dislocation of the wrist-joint backwards. Of these, twenty- 
three are said to have been luxated backwards and ten forwards ; of this 
entire number only seven, five backwards and two forwards, are free 
from all objection. Of the twenty-six cases of doubtful or unsatisfactory 
dislocations, sixteen were complicated with fracture of one of the bones 
or processes connected with the joint ; three were compound, three were 
incomplete, two w r ere arthritic or pathological specimens, and two were 
objected to from other causes. Of the thirty-three so-called dislocations, 
the sex is recorded here in fourteen instances; of these eleven were 
males and three were females. Of the seven cases classed as genuine 
ones, one post-mortem was made (case of M. Malle), which confirmed 
the diagnosis ; in six remaining cases the patients regained the use of 
the limb in a very short time, without a tendency to displacement or 
deformity. Of these seven cases accepted as genuine, two backward 
dislocations were produced, the force of the fall being received, in one 
instance, on the dorsum of the hand (Hamilton's) ; in the other upon 
the palmar surface (Parker's) ; in M. Malle's case, a forward displace- 
ment, the presumption is that the patient fell on the palm of his hand, 
but this is not definitely stated ; and in the four remaining cases this 
point is not specified. He lays down the following practical conclusions, 
which may be derived therefrom : 1st. The wrist-joint may be dislocated 
backwards or forwards without fracture or a rupture of the integuments ; 
both are extremely rare ; the backward displacement is the most fre- 
quent. 2d. Cases of so-called dislocation of the wrist may be associated 
with fracture of the radius and ulna, or with either of these bones 
separately, with both styloid processes, or either of them, or with frac- 
ture of the articulating surface of the radius; no instance has been 
recorded of a dislocation of this joint complicated with fracture of the 
carpal bones. 3d. Dislocation of the wrist backwards or forwards may 
be complicated with rupture of the integuments anteriorly or posteriorly, 
or laterally, with or without fracture of the styloid processes.") 1 

3 1. Dislocations of the Carpal Bones Backwards. 

Causes. — The same casualty, namely, a fall upon the palm of the 
hand, which, as we have elsewhere noticed, produces frequently a frac- 
ture of the lower end of the radius, occasionally a dislocation of the 
radius and ulna backwards, at the elbow-joint, may also, it is believed, 
occasion sometimes a dislocation of the carpal bones backwards. In 
several of the cases reported, this cause has been assigned ; but in the 
only example of simple dislocation which has ever come under my notice, 
and which I have every reason to believe was a simple dislocation 

1 F. L. Parker, Med. Rec, Nov. 1. 1871. 



712 DISLOCATIONS OF THE WEIST. 

unaccompanied with a fracture, the carpal bones were thrown back by a 
fall upon the back of the hand. The following is a brief account of the 
case : — 

The Rev. Stephen Porter, of Geneva, N. Y., set. 75, while walking 
with his son after dark, and holding in his right hand a satchel, slipped 
and fell. In the effort to save himself, and still retaining his grasp 
upon the satchel, his right hand struck the sidewalk flexed, and in 
such a way that the whole force of the fall was received upon the 
back of the hand and wrist, thus throwing the hand into a state of 
extreme flexion. In less than twenty minutes he was at my house. 
No swelling had yet occurred, and the moment I looked at the wrist I 
said to him, "You have broken your arm ;" so much did it resemble a 
fracture of the lower end of the radius. A further examination led me 
to a different conclusion. The palmar surface of the wrist presented an 
abrupt rising near the radio-carpal articulation, the summit of which 
was on the same plane and continuous with the bones of the forearm, 
and a corresponding elevation existed upon the dorsal surface termina- 
ting in the carpal bones and hand ; the hand was slightly inclined back- 
wards, but the fingers were moderately flexed upon the palm. To this 
extent the accident bore the features of a fracture of the radius ; but the 
hand did not fall to the radial side ; the projections upon the palmar and 
dorsal surfaces were more abrupt than I had ever seen in a case of frac- 
ture, and which, if it were a fracture, would imply that the broken ex- 
tremities had been driven off from each other completely ; the most 
salient angles of these projections were abrupt, but not sharp or ragged; 
the styloid apophyses could be distinctly felt, and I was not only able 
to determine that they were not broken, but, by observing their rela- 
tions to the palmar and dorsal eminences, it was easy to see that these 
latter corresponded to the situation of the articulation. 

In addition to these evidences that I had to deal with a dislocation, 
and not a fracture, we had the testimony furnished by the redaction, 
which was not made, however, until by every possible means the diag- 
nosis was definitely settled. Seizing the hand of the gentleman with 
my own hand, palm to palm, and making moderate but steady extension 
in a straight line, the bones suddenly resumed their places with the 
usual sensation or sound accompanying reductions. There was no 
grating, or chafing, or crushing, nor was the reduction accomplished 
gradually, but suddenly. To test still further the accuracy of the diag- 
nosis, I now pressed forcibly upon the wrist from before back, but with- 
out producing any degree of displacement, nor could any crepitus still 
be detected. No splint was applied, and on the following morning Mr. 
Porter preached from one of the pulpits in the city, only retaining his 
arm in a sling. 

Sixteen months after the accident, September 15, 1858, this gentle- 
man again called upon me, and I found the arm perfect in all respects, 
except that it w T as not quite as strong as before ; the lower extremity of 
the ulna was preternaturally movable, and occasionally he felt a sudden 
slipping in the radio-carpal articulation. 

Pathological Anatomy.— In the examples of compound or compli- 
cated dislocations, which have been exposed by dissections, the posterior 



DISLOCATIONS OF THE CARPAL BONES BACKWARDS. 713 

and lateral ligaments have been found extensively torn, as also fre- 
quently the anterior ligament, with or without separation of the radial 
or ulnar apophyses ; the extensor muscles torn up from the lower part 
of the forearm and displaced ; the first row of the carpal bones lying 

Fig. 288. 




Dislocation of the carpal bones backwards. (From Fergnsson.) 

underneath the tendons, and upon the bones of the forearm, sometimes 
having been carried directly upwards, sometimes upwards and a little 
inwards, and at other times upwards and outwards ; the arteries and 
nerves have occasionally escaped serious injury, but more often they 
have been displaced, bruised, or torn asunder. 

Such are, briefly, the pathological circumstances which may be sup- 
posed to exist, also, in a lesser or greater degree, in nearly all cases of 
simple dislocations. 

In compound dislocations, however, the muscles, or rather the ten- 
dons, are twisted, torn, and thrust aside, producing very extensive 
lesions among the deeper structures of the forearm and hand before the 
integuments can be made to yield. 

On the 2d of May, 1852, Silas Usher, set. 54, had his right arm 
caught between the bumpers of two cars, bruising the hand and dislo- 
cating the carpal bones backwards, the radius and ulna being thrown 
forwards and pushed completely through the skin into the palm of the 
hand. Most of the flexor tendons had been merely thrust aside, but one 
or two were torn asunder ; the median nerve was torn off, but the radial 
and ulnar nerves were apparently uninjured, and there was no fracture. 
The patient being a temperate man, in perfect health, and the bones 
having been easily replaced by moderate extension, it was determined to 
make an effort to save the arm. The limb was therefore laid on a care- 
fully padded splint, and cool water lotions diligently applied. Phleg- 
monous erysipelas began to develop itself on the third day ; and on the 
ninth, gangrene having attacked the limb, I amputated a little above the 
middle of the humerus. On the fourteenth day hemorrhage occurred 
suddenly from the stump, and when I reached him he was pulseless and 
dying. 

The result demonstrated the error of the attempt to save the limb 
without resection of the lower ends of the bones of the forearm. I 
46 




714 DISLOCATIONS OF THE WRIST. 

will also add, that according to my later experience it would have been 
better, if an attempt were to be made to save the hand without resection, 
to have used warm instead of cold water, and when gangrene occurred, 
to have applied hot water, or water at a temperature of 105° or 110° 
F., either in the form of fomentation or a bath. 

Symptoms. — The usual signs have already been sufficiently stated in 
the example which we have given. The most important diagnostic 

marks are found in the abruptness 
FlG - 289 - of the angles formed by the project- 

ing bones ; the relation of these prom- 
inences to the styloid apophyses ; in 
the total absence of crepitus ; and in 
the reduction, which is accomplished 
easily, suddenly, and with a charac- 
teristic sensation. If a fracture com- 
Disiocation of the carpal bones backwards. plicates the accident, crepitus may 

also be present. It should be re- 
membered, moreover, that when the styloid process of the radius is 
broken, if the hand is moved backwards and forwards this process will 
move also, which might lead to the supposition that the radius was 
broken higher up, and that it was not a dislocation at all. 

Prognosis. — In compound dislocations the prognosis is exceedingly 
grave, unless the surgeon determines to resort to amputation, or, what 
is generally much preferable, to resection. In dislocations complicated 
with fracture of the posterior edge of the articulating surface of the 
radius (" Barton's fracture" 1 ), some difficulty may be experienced in 
retaining the bones in place ; but when this fracture does not exist, the 
posterior margin of the articulation, considerably elevated above its 
anterior margin, constitutes a sufficient protection against a reluxation 
in that direction. In all cases, also complicated with fracture, even of 
an apophysis, intense inflammation and swelling are likely to follow, and 
the danger of a permanent anchylosis is greatly increased. 

Treatment.— Extension in a straight line has generally been found 
sufficient to accomplish the reduction ; to which may be added a slight 
rocking or lateral motion, if necessary. 

The reduction may be effected also by pressing the hand backwards, 
while the surgeon pushes the carpus downwards from behind and above, 
in the direction of the articulation. 

Unless a tendency to displacement exists, no splints or bandages of any 
kind ought to be applied, but it should be treated by rest and fomenta- 
tions until all danger from inflammation has passed. 

§ 2. Dislocations of the Carpal Bones Forwards. 

The causes, mechanism, symptoms, pathology, treatment, etc., of this 
accident resemble in so many points those of the preceding dislocation, 
with only the differences necessarily due to a change in the direction of 

1 Philadelphia Medical Examiner, 1838. 



DISLOCATIONS OF THE CARPAL BONES FORWARDS. 715 




Dislocation of the carpal bones forwards. 



the bones, that I find it not worth while to do more than to relate one sin- 
gle example, contained in Bransby Cooper's edition of Sir Astley's work 
on Fractures and Dislocations. The case did not come under the ob- 
servation of Mr. Cooper himself, 

but was related to him by Mr. Fig. 290. 

Haydon, a surgeon residing in 
London. It is especially inter- 
esting as furnishing an example 
of a dislocation of both wrists at 
the same moment, and from simi- 
lar causes, but in opposite direc- 
tions. 

A lad, aged about thirteen years, 
was thrown violently from a horse 
on the 11th of June, 1840, strik- 
ing upon the palms of both hands 
and upon his forehead. The left 
carpus was found to be dislocated 
backwards, the radius lying in 
front and upon the scaphoides 
and trapezium. The right carpus was dislocated forwards, the radius 
and ulna projecting posteriorly, and the bones of the carpus forming an 
" irregular knotty tumor terminating abruptly" anteriorly. 

A very careful examination was made to determine what parts came 
in contact with the resisting force, but although the palms of both hands 
were extensively bruised, there was 
not the slightest bruise on the back 
of either hand. Nor were the gen- 
tlemen present able to find any evi- 
dence whatever that the dislocation 
was accompanied with a fracture. 
" Moreover," says Mr. Haydon, 
" we were strengthened in our opin- 
ion that this was a case of disloca- 
tion, unattended with any fracture, because the dislocations appeared so 
perfect; the two tumors in each member so distinct ; the reduction so com- 
plete ; the strength of the parts after reduction so great ; and lastly, by 
the very trifling pain felt after reduction, for within an hour after, the 
patient could rotate the hand, and supinate it when pronated — this could 
not, we believe, have been done had there existed a fracture." 



Fig. 291. 




Dislocation of the capal bones forwards 



716 DISLOCATIONS OF THE LOWER END OF ULNA 



CHAPTEE XI. 

DISLOCATIONS OF THE LOWER END OF THE ULNA (INFERIOR 

RADIO-ULNAR). 

In connection with fractures of the lower end of the radius this acci- 
dent is not very uncommon. 1 have myself met with it under these cir- 
cumstances several times ; but without a fracture it is quite rare. Dupuy- 
tren met with but two cases in his long and extensive practice. Sir Astley 
Cooper does not record a single instance, and many surgeons affirm that 
they have never seen the dislocation in question. I have met with three 
cases uncomplicated with fracture. 

§ 1. Dislocations of the Lower End of the Ulna Backwards. 

To the eleven or twelve examples collected and referred to by Mal- 
gaigne, I am only able to add two cases of ancient luxation seen by 
myself. 

Causes. — Duges mentions the case of a little girl in whom the accident 
occurred in both arms, but at different periods, by being lifted by the 
hands. One of the patients seen by Desault, a child five years old, had 
the ulna dislocated backwards by extension accompanied with forced pro- 
nation ; and in another example, cited by him, forced pronation alone, as 
in wringing wet clothes, was found to have been sufficient. In Herteaux's 
case the patient had fallen upon her wrist. 

Pathological Anatomy. — Rupture of the synovial membrane (sacci- 
form ligament), and also rupture of the internal lateral ligament, and of 
the triangular fibro-cartilage, the little head or lower extremity of the 
ulna abandoning its socket in the radius, and being thrown backwards, 
or in some cases backwards and outwards, so as to cross obliquely the 
lower end of the radius ; or it may incline inwards as well as backwards. 

House Surgeon Owen, of Bellevue Hospital, called my attention, 
April 4, 1869, to an example of this dislocation in ward 28. The 
patient, Mary Fay, set. 27, having puerperal mania, was confined some 
time in February, in a strait-jacket, and the accident happened during 
this confinement, about six weeks before she came under my notice. 
I found the right ulna displaced backwards so that its articular surfaces 
were completely separated ; but it did not override the radius, and with 
moderate pressure it was returned to place. The dislocation and re- 
duction, which had been frequently made by the house staff since the 
accident, caused no pain, but was accompanied with a slight grating 
sensation. 

Dr. Moore, of Rochester, has found this dislocation existing in con- 
nection with a Colles fracture. In the chapter on fractures of the radius 



DISLOCATIONS OF LOWER END OF ULNA FORWARDS. 717 

I have made especial reference to the views of this distinguished surgeon 
upon this subject. 

Prognosis. — In recent cases the reduction has generally been accom- 
plished without difficulty, and in only three or four instances has the 
bone become spontaneously displaced. 

Loder reduced the ulna after eight weeks, and Rognetta after sixty 
days. In one of the examples to which I have already referred as 
having been seen by myself, the ' dislocation had existed twenty years, 
the accident having occurred in Ireland when the person was fifteen 
years old. When I examined the arm, July 21, 1850, the right ulna 
projected backwards and a little outwards, about half an inch. He said 
he had been lame with it for several years, but the motions of the wrist- 
joint were now completely restored, and both pronation and supination 
were perfect. 

Symptoms. — The hand is usually fixed in a position midway between 
supination and pronation. Boyer, however, found the hand in a state of 
extreme pronation. The extremity of the ulna is felt and seen distinctly 
upon the back of the wrist, prominent and movable ; and the styloid 
process is no longer in a line with the metacarpal bone of the little finger ; 
the fingers, hand, and forearm are slightly flexed. 

Treatment. — The reduction may be accomplished by holding firmly 
upon the radius and at the same moment pushing the ulna forcibly 
toward its socket ; or by simply supinating the hand strongly. Some 
cases demand also extension and counter-extension. 

Generally the bone has been found to remain in its place without 
assistance, yet in three or four of the examples upon record the constant 
tendency to displacement when the pressure was removed has rendered 
it necessary to employ splints and compresses. 

§ 2. Dislocations of the Lower End of the Ulna Forwards. 

The dislocation forwards is said by Malgaigne to be more rare than the 
dislocation backwards. In addition to the nine cases collected by him, I 
have been able to add one reported by Parker, of Liverpool, one by R. 
F. Weir, of New York, 1 and one seen by myself; leaving, therefore, a 
difference of only one or two in favor of the luxation backwards, and not 
sufficient, I think, to warrant any positive conclusions as to the relative 
frequency of the two accidents. 

While the dislocation backwards is usually caused by violent prona- 
tion of the hand, this dislocation is most often occasioned by violent 
supination. The hand is therefore generally found to be supinatecl forci- 
bly, and the projection formed by the end of the bone is seen upon the 
front of the wrist instead of the back. 

By pushing the ulna toward its socket while an attempt is made to 
flex the hand, or by extension, supination, etc., it is made to resume its 
position readily. In the case reported by Parker, however, the reduc- 
tion was effected only while the hand was pronated. 

Parker's case is thus related: — 

1 Weir, Arch. Clin. Surg , April 15, 1877, p. 10. 



718 DISLOCATION'S OF THE LOWER END OF ULNA. 

"John Dalton, aged forty, applied to the hospital, Aug. 9, 1841, 
under the following circumstances : — 

" States that he is a carter, and falling down, the shaft of the cart fell 
upon his hand and forearm, in such a way as to supinate them forcibly. 
He complains of pain in the left wrist. The forearm is supinated, and 
cannot be pronated, the attempt causing much suffering. The wrist-joint 
can be flexed or extended without much pain. On looking at the back 
of the wrist, the appearance is characteristic ; the natural prominence 
of the ulna is wanting ; an evident depression exists, as if the lower end 
of the ulna had been dissected out ; it can be traced, however, on a 
plane anterior to the radius, its button-like head being distinctly felt 
under the flexor tendons. Several ineffectual and very painful attempts 
were made to accomplish the reduction, by pushing the head of the ulna 
into its natural situation. This was at last effected by seizing the hand 
to make extension (counter-extension being made at the elbow), then 
forcibly pronating the hand, at the same time pressing backwards the 
dislocated head of the bone with the fingers of the left hand. After 
persevering for a short time, the bone was felt to assume its natural 
position, the wrist acquired its usual appearance, and the ordinary move- 
ments of the joint could be readily performed. There was no tendency 
to redislocation, and the man was dismissed with directions to keep the 
bone quiet, and to foment it. He attended as an out-patient for two or 
three days, after which, complaining of nothing but a little weakness in 
the part, a bandage was applied, and ordered to be worn for a short time." 1 

The following is the case seen by me : — 

Wm. Carroll, set. 27, had his left arm caught in machinery and 
" twisted," or rotated violently, causing a simple dislocation of the ulna 

Fig. 292. 




Dislocation of lower end of ulna forwards. Case of Wm. Carroll. 

forwards. No attempt was made at reduction. He consulted me Nov. 
14, 1878, several months after the accident occurred, when I found the 
lower end of the ulna projecting on the palmar surface, and inclined 
toward the radius. It could be reduced easily, but would not stay in 
place ; pronation was lost, but all other movements of the arm were pre- 

1 Parker, Amer. Journ. Med. ScL, April, 1843, p. 470, from Lond. and Edin. 
Month. Journ. Med. ScL, Dec. 1842. 



DISLOCATIONS OF THE CARPAL BONES. 719 

served. He was a laboring man, and declined to have the necessary 
apparatus applied to secure permanent reduction, since it would prevent 
his immediate return to work. 

Dr. Weir's patient was a woman, set. 49, in whom the accident oc- 
cured, Feb. 9, 1877, by a direct force applied to the back of the ulna 
near its lower end. She was seen within a few minutes by Dr. Weir, 
the wrist presenting a singular deformity. It was much narrower than 
the other, and in place of the usual prominence, posteriorly, there was 
a deep depression, and the head of the ulna projected slightly in front. 
The hand was semiflexed and nearly supinated. An attempt to reduce 
the dislocation without an anaesthetic failed ; but under the influence of 
an anaesthetic the reduction was accomplished easily, by direct pressure 
made upon the lower end of the ulna. The recovery of the use of the 
hand was speedy and complete. 

It is proper to add that a more or less anterior projection of the lower 
end of the ulna is quite common in connection with a Colles fracture ; 
and that it often remains thus prominent after the fragments of the 
radius are replaced and the cure is consummated. 



CHAPTER XII. 

DISLOCATIONS OF THE CARPAL BONES (AMONG THEMSELVES). 

Bound together on all sides by strong ligaments, and enjoying only a 
very limited degree of motion among themselves, the carpal bones seldom 
become displaced except in gunshot wounds, or in connection with exten- 
sive lacerations and fractures of the neighboring parts. Simple disloca- 
tions, or rather subluxations of these bones, do, however, occasionally 
take place, but, so far as we have been able to ascertain, except in the 
case of the pisiform, only in one direction, namely, backwards. 

The bones of the carpus, which are said occasionally to have suffered 
simple backward subluxation, are the semilunar, cuneiform, and pisiform 
of the first row, and the magnum and unciform of the second row. 

Magnum. — Richerand, the editor of Boyer's Lectures, says that he 
once met with a subluxation of the os magnum backwards, of which he 
has given the following account: " Mrs. B., in a labor pain, seized vio- 
lently the edge of her mattress, and squeezed it forcibly, turning her 
wrist forwards ; she instantly heard a slight crack, and felt some pain, 
to which her other sufferings did not allow her to attend. Fifteen days 
afterwards, happily delivered, and recovered by the care of Professor 
Baudelocque, she showed her left hand to this celebrated accoucheur, 
and expressed her disquietude about the tumor which appeared on it, es- 
pecially when much bent. I was called to visit the lady. I found that 
this hard circumscribed tumor, which disappeared almost totally by ex- 
tending the hand, was formed by the head of the os magnum, luxated 
backwards ; I replaced it entirely by extending the hand, and making 



720 DISLOCATIONS OF THE CARPAL BONES. 

gentle pressure on it. As the affection did not impede the motion of 
the part, as the tumor disappeared on extending the hand, and as it 
would have been but little apparent in any state of the hand had Mrs. 
B. been more in flesh, I advised her not to be uneasy about it, and to 
apply no remedy to it." 1 

Richerand adds also that Boyer and Choparthad each met with the 
same dislocation. 

Bransby Cooper saw the os magnum displaced backwards in a stout, 
muscular young man, by a fall upon the back of the hand when in ex- 
treme flexion. The hand remained slightly bent, and the projection of 
the os magnum was very distinct. Reduction was attempted by extend- 
ing the whole hand, at the same time making pressure upon the displaced 
bone ; this not succeeding, extension was made from the middle and fore- 
fingers only, while pressure was kept up on the os magnum, when sud- 
denly the bone resumed its natural position. On flexing the hand, how- 
ever, the dislocation was immediately reproduced ; and it became neces- 
sary to apply a compress and splint. For several days after, he was in 
the habit of pushing it out by flexing the hand, in order that the young 
men at Guy's Hospital might see its reduction ; which was always easily 
accomplished by simply pushing upon it. 

Magnum and Cuneiform. — Sir Astley says that both the os magnum 
and cuneiform are sometimes thrown a little backwards, from simple 
relaxation of the ligaments, producing a great degree of weakness, so as 
to render the hand useless unless the wrist be supported ; and he men- 
tions the case of a young lady in whom the os magnum was thus dis- 
placed, and who was obliged to give up her music in consequence ; for 
when she wished to use her hand, she was compelled to wear two short 
splints, made fast to the back and forepart of the hand and forearm. 
Another lady, whose hand was weak from a similar cause, wore, for the 
purpose of giving it strength, a strong steel chain bracelet, clasped very 
tightly around the wrist. 2 

Pisiform. — South says that Gras has described a dislocation of the 
pisiform bone, in the Gazette Med., vol. iii., 18^5, 3 and Fergusson says 
he has known an example in which this bone was detached from its lower 
connections by the action of the flexor carpi ulnaris. 4 Little benefit, he 
thinks, can be expected from any attempts to keep it in place when it is 
dislocated, nor is its displacement of much consequence. In case it were 
dislocated without a rupture of the flexor carpi ulnaris, it would neces- 
sarily be drawn more or less upward, in the direction of the tendon and 
muscle. In children this bone moves very freely upon the cuneiform, 
and even in adults it is quite movable, and I have seen a surgeon mistake 
this natural mobility for a partial luxation. 

Lunare. — Erichsen thinks he has seen a dislocation of the os lunare 
produced by a fall upon the hand when forcibly flexed. By extension 
and pressure it was easily replaced, but when the hand was flexed the 
dislocation was immediately reproduced. 5 

1 Richerand, Boyer's Lectures on Diseases of Bones, Amer. ed., 1805, p. 261. 

2 Sir A. Cooper, op. cit., p. 435. 

3 Note to Chelius, by South, op. cit., p. 234. 

4 Fergusson, op. cit., p. 190. 

5 Erichsen, Science and Art of Surg., Amer. ed., 1859, p. 259. 



DISLOCATIONS OF THE METACARPAL BONES. 721 

Notwithstanding that Sir Astley, Miller, and others have taught that 
the cuneiform bone is liable to displacement, and that South has affirmed 
the same of the unciform, I have found no account of an example of 
simple dislocation of single carpal bones except in the cases of the os 
magnum, pisiformis, and lunare, as above mentioned. 

Middle Carpal Articulation. — Maisonneuve has reported an example 
of simple dislocation, without wound of the integuments, at the middle 
carpal articulation. A man had fallen forty feet, and was carried dying 
to the Hotel Dieu. The symptoms were almost precisely those of a dis- 
location of both rows of the carpal bones backwards. The reduction 
was not accomplished during life, but after death a simple effort of trac- 
tion was sufficient to replace the bones. The dissection showed that 
the bones of the seconds row were almost completely separated from those 
of the first, upon which they were overlapped backwards. A small frag- 
ment of both the scaphoicls and cuneiform remained attached to the second 
row, but, with this exception, the separation was complete. 1 



CHAPTEE XIII. 

DISLOCATIONS OF THE METACARPAL BONES (CARPO- 
METACARPAL ARTICULATIONS). 

§ 1. Dislocation of the Metacarpal Bone of the Thumb Backwards. 

Malgaigne has seen two complete dislocations of this bone backwards 
upon the trapezium, and he mentions two other cases seen by Michon and 
Bourguet, respectively. 2 

Causes. — They have been found to be caused by falls upon the back of 
the distal extremity of the thumb, forcing the metacarpal bone into a posi- 
tion of extreme flexion ; and also by blows received upon the end of the 
thumb, forcing it into an opposite direction. 

Symptoms. — The symptoms are sufficiently clear, although the posi- 
tion of the thumb is not always the same. It has been found perfectly 
straight, without any inclination either way, or flexed more or less, with 
the metacarpal bone also inclined inwards toward the palm. The motions 
of the joint are interrupted, and the proximal extremity of the meta- 
carpal bone riding upon the back of the trapezium, projects sensibly in 
this direction, and the trapezium is also felt unusually prominent under 
the thenar eminence. The overlapping varies from a line or two to three- 
quarters of an inch. In the patient mentioned by Bourguet, the head 
of the metacarpal bone almost reached the styloid process of the radius. 

Treatment. — The reduction is to be effected by extension alone, or by 
extension with moderate pressure. In two of the examples reported, 

1 Maisonneuve, Malgaigne, op. cit., from Mem. de la Soc. de Chirurg., t. ii. 

2 Malgaigne, op. cit., vol. ii. p. 728. 



722 



DISLOCATIONS OF THE METACARPAL BONES. 



Fig. 293. 




although the reduction was accomplished very easily, the dislocation was 
reproduced when the extension ceased, and it became necessary to apply 
splints. Malgaigne did not observe, in the case seen by him, any such 
tendency to displacement. 

In the case of Bourguet's patient the reduction was never accom- 
plished, although the attempt was made on the second day by a surgeon, 
and repeated after about two months by Bourguet himself. 

Fergusson, who has met with several of these dislocations, says that 
he has seen even a splint and roller fail of keeping these bones in place. 
The following is the only example seen by myself : Charles Flannigan, 
get. 27, caused an incomplete backward luxation of this bone by striking 
a man with his clenched fist. It was never treated by a surgeon ; and 
although it always projected a little, and the joint was so loose that he 
could easily push it into place, it caused him no inconvenience, and after 
a time the motions became as free as in the other thumb. 

About four weeks before he called upon me, and twenty-five years after 
the first accident, he wrenched it again. He was then employed as a 
stage driver, and was fifty-three years old. The dis- 
location was now complete, and the overriding was 
about one-quarter of an inch. The thumb was nearly 
straight, the line of its axis being nearly parallel 
with that of the bones of the forearm or only slightly 
flexed. I reduced it easily by extension, and applied 
a gutta-percha splint, but I have never seen him since, 
and do not know the result. 

Incomplete backward luxations of the metacarpal 
bone of the thumb seem to be produced by the same 
causes which cause complete luxations. The signs of 
this accident are sometimes obscure, owing to the 
presence of considerable swelling, and they have been 
often left unreduced. 

In order to the accomplishment of the reduction 
it will be necessary to employ extension, Avhile at the 
same moment pressure is made directly upon the dis- 
placed extremity : and to maintain it in place a splint 
and bandage will be required. It is doubtful, how- 
ever, whether in any case the bone can be made to 
retain so completely its original position as not to 
leave a perceptible deformity. 

Peter Golden, set. 16, caused a partial luxation of 
this bone backwards by a blow upon the back of the distal end. Two 
medical men whom he consulted on the first and seventh day after the 
accident failed to recognize the displacement. On the thirteenth day 
he consulted me. The projection of the metacarpal bone was now quite 
manifest, the swelling having in a great measure disappeared. Having 
secured the accompanying photograph (Fig. 293), he was placed under 
the influence of ether, and the reduction easily accomplished, and with 
a carefully padded splint of gutta-percha, which included a portion of 
the arm, it was retained in place. At the end of six or eight months he 
was again examined by me. The motions of the joint were nearly as 




Case of Peter Golden. 



DISLOCATIONS OF METACARPAL BONES OF FINGERS. 723 

free as before, but there remained a slight prominence of the metacarpal 
bone. 

The reader is referred to one other case seen by me after the disloca- 
tion had become complete, and described under complete dislocations of 
this bone backwards. 

§ 2. Dislocations of the Metacarpal Bone of the Thumb, Forwards. 

Probably Sir Astley Cooper has reference to an accident of this cha- 
racter when he says : Speaking of " Dislocation of the Head of the 
Metacarpal Bone from the Trapezius." In the cases which I have seen of 
this accident the metacarpal bone has been thrown inwards, between the 
trapezium and the root of the metacarpal bone supporting the forefinger ; 
it forms a protuberance toward the palm of the hand ; the thumb is bent 
backwards, and cannot be brought towards the little finger." 1 

Sir Astley does not, however, refer to any of the cases which he has 
seen, and Malgaigne says he has not met with such a case, or found one 
recorded. My own experience and observation correspond with that of 
Malgaigne ; although I must confess I have not made it a special purpose 
to look for examples in surgical writings. 

One can never call in question the accuracy of Sir Astley Cooper's 
statements, however, and I shall, therefore, add what he has said of the 
mode of reduction. " For the facility of reduction, as the flexor muscles 
are made stronger than the extensors, it is best to incline the thumb to- 
ward the palm of the hand during the time extension is making, and thus 
the flexors become relaxed and their resistance diminished. The exten- 
sion must be steadily and for a considerable time supported, as no sud- 
den violence will effect the reduction. If the bone cannot be reduced by 
simple extension, it is best to leave the case to the degree of recovery 
which nature will in time produce, rather than divide the muscles, or run 
any risk of injuring the nerves and bloodvessels." 

Vidal (de Cassis) says he met with an incomplete forward luxation, 
which he reduced readily, but the patient removed the dressings and the 
dislocation was reproduced, and the bone was not again replaced. 2 

§ 3. Dislocations of the Metacarpal Bones of the Fingers. 

Examples of these accidents are so rare that no attempt will be made 
to establish systematically the causes, symptoms, or treatment. Such 
examples as I have found recorded, or as have couie under my own ob- 
servation, will be, however, briefly related. 

Dislocations of the Metacarpal Bones of the Fingers Backwards. — 
Roux has recorded one complete dislocation of the second metacarpal bone 
upon the os magnum, caused by an explosion in a mine. It was reduced 
by pressure and extension, but could only be retained in place when the 
hand Avas flexed. The patient died on the tenth day, and the diagnosis 
was verified by the autopsy. 

1 Sir Astley Cooper's Treatise on Dislocations, and on Fractures of the Joints, 2d 
London ed., 1823, p. 526. 

2 Vidal (de Cassis), Traite de Path. Ext., 3d Paris ed., vol. ii. p. 564. 



724 DISLOCATIONS OF THE METACARPAL BONES. 

The remaining backward dislocations of the metacarpal bones of the 
fingers, and all others that I have found recorded, were incomplete, and 
were generally produced by striking with the clenched fist. I will men- 
tion a few of several cases which have come under my notice. 

In April, 1849, Stephen Peterson, get. 24, was admitted into the 
Buffalo Hospital of the Sisters of Charity, with a partial dislocation 
backwards of the proximal ends of the metacarpal bones of the index 
and great fingers of the right hand ; produced, as he affirms, by striking 
a man with his clenched fist, about one year previous. He says that he 
called upon a surgeon immediately, but he was unable to keep the bones 
in place. The projection was very manifest at the time of my examina- 
tion, and the hand had never recovered the power of grasping bodies 
firmly. 

During the same year I found in the hospital a precisely similar case, 
in the person of Francis McCoit, aet. 32, a sailor, which had occurred 
four years before, in consequence of a blow given with his fist. The 
same bones were partially displaced backwards, and remained unre- 
duced. This man had also consulted a surgeon soon after the injury 
was received. 

In both of the above examples I instituted a careful examination to 
determine whether it was not the bones of the carpus which were thus 
displaced ; but the result was conclusive as to the nature of the accident, 
and I have obtained casts of both, in order to illustrate partial disloca- 
tions of the metacarpal bones. 

In 1866 I met with a similar case, only that the metacarpal bone of 
the index finger was alone dislocated, at Bellevue Hospital, in a woman 
28 years of age, caused by falling upon her hand with the fingers closed. 
Reduction was easily effected. 

The following example of dislocation of all the metacarpal bones, 
except that of the thumb, is probably without a parallel. Corporal Gar- 
rigan, at the battle of Fredericksburg, Dec. 13, 1862, while holding his 
gun at " ready" was hit by a ball on the back and ulnar side of his left 
hand, the ball traversing the back of the hand between the last row of 
carpal bones and the skin, and emerging on the radial side, sending the 
carpal bones forwards and dislocating the metacarpal bones backwards. 
Great SAvelling ensued, and the nature of the accident was not known for 
some months. When I examined the hand, five years later, the dis- 
placement was very conspicuous ; no fragments of bone had ever escaped. 
The motions of all the fingers, except the index and little fingers, were 
unimpaired. 

Dislocations of the Metacarpal Bones of the Fingers forwards. — Ac- 
cording to Malgaigne, Bourquet met with a forward luxation of the 
metacarpal bone of the index finger, caused by a great force applied to 
the back of the hand near the carpus. Reduction was effected by ex- 
tension and pressure. With the aid of splints it was retained in place, 
and a cure effected. 

The following case of forward luxation of the second metacarpal bone 
at its proximal end has been reported to me by J. Marsh, Asst. Surg. 
U. S. A.:— 

On the 1st of April, 1868, Corporal Charles C, set. 25, was struck 



DISLOCATIONS OF FIKST PHALANX OF THUMB 



725 



accidentally on the back of his right hand by a hammer weighing seven 
pounds. The hand was at the time firmly clenched, and covered with a 
buckskin glove. The blow was received obliquely. Dr. Marsh saw him 
half an hour after the accident. A marked depression existed on the 
back of the hand, corresponding to the proximal end of the bone, and 
from this point a gradual elevation of the bone could be traced to its 
natural level at the distal end. On the palm of the hand the displace- 
ment was equally manifest. In this position it was fixed, and seemed 
immovable. It was easily and quickly reduced, however, by making 
extension from the fingers, while at the same moment pressure was made 
by the thumb in the palm of the hand. It returned to its place with the 
usual sensation accompanying a reduction of a dislocation, and the de- 
formity at once disappeared; a ball of tow was now placed in the palm 
of the hand, and secured there by a roller. On the 13th of April he 
returned to duty, but his hand did not acquire its full strength for some 
time longer. 



CHAPTEE XIV. 

DISLOCATIONS OF THE FIRST PHALANGES OF THE THUMB 
AND FINGERS (METACARPOPHALANGEAL). 



§ 1. Dislocations of the First Phalanx of the Thumb Backwards. 

This bone may be dislocated backwards or forwards, but most fre- 
quently the dislocation is backwards. I have met with the backward 
dislocation ten times. 

Causes. — The backward dislocation is occasioned generally by a fall 
or blow upon the distal end and palmar surface of the thumb. 

Symptoms. — I have found the two phalanges in the same axis "with 
tbe metacarpal bone at least twice ; that is, neither flexed nor tilted 
backwards ; but in most of the cases the first phalanx inclines backwards 
upon the metacarpal bone, and the second phalanx 
is flexed upon the first, as seen in the illustration. 

Treatment. — The reduction is sometimes, in re- 
cent cases, accomplished with great ease, as the 
following examples will illustrate: — 

A servant girl, set. 25, fell down a flight of 
steps Nov. 15, 1850, striking upon the inside of 
her right hand and thumb. When I saw her, only 
a few minutes afterwards, I found the first pha- 
lanx standing back almost at a right angle with the 
metacarpal bone, and the second phalanx also 
flexed to a right angle with the first. Assisted by 
my pupil, Mr. Boardman, the reduction was 
effected in about twenty seconds, by bending the Dislocation f the fir «t 

£1 , /» i ,i , J a phalanx of the thumb back- 

nrst phalanx farther back, and at the same moment wa rds. 




726 OF FIRST PHALANGES OF THUMB AND FINGERS. 

pressing the proximal end of this phalanx forwards in the direction of the 
joint. Without employing great force, the reduction took place sud- 
denly and with a snap. Very little swelling followed, and in three 
weeks she was able to use her needle without inconvenience. 

Michael Wolfe, set. 35, fell from a height, causing a fracture of his 
left arm, and a dislocation of his right thumb backwards. I saw him 
within two hours after the accident. The thumb was much swollen, and 
its position the same as in the case just described. Although Wolfe was 
a strong muscular man, the reduction was accomplished in a few seconds 
by applying over the last phalanx the Indian toy called a u puzzle," 
and making extension in a straight line, while an assistant made counter- 
extension from the hand and wrist. The use of the joint was soon com- 
pletely restored. 

Examples, however, are constantly occurring, which are only reduced 
after long-continued and painful efforts, or which, indeed, completely 
exhaust the patience and baffle the skill of the most experienced 
surgeons. 

Mary J. S., set. 23, fell upon her right hand with her fingers and 
thumb extended, in September, 1853, and dislocated this bone back- 
wards. A young surgeon attempted to reduce the dislocation half an 
hour after the accident, by the same manoeuvre adopted by myself 
successfully in the case of the servant girl, only that he made exten- 
sion upon the last phalanx at the same moment. The surgeon believes 
that the bone was reduced, but one week later he found it displaced, 
and, as he believes, reduced it again. The same thing occurred a third 
time. 

Six months after this, the girl consulted me to ascertain what could 
be done for her relief. The thumb occupied the usual position, and 
admitted of no motion except at the carpo-metacarpal articulation. 

In May, 1848, having been called to see G. H., who had attempted 
suicide by cutting his throat, my attention was arrested by the appear- 
ance of his left thumb, and which I found to be occasioned by an 
ancient dislocation of the first phalanx backwards. The accident had 
occurred, he afterwards told me, twelve years before, in consequence of 
a fall while wrestling. A very respectable country surgeon was called, 
and made three several attempts to reduce it, but failed. 

The several bones of the thumb occupied their usual positions, that 
is to say, the positions which they usually occupy in this dislocation, 
yet notwithstanding the almost complete anchylosis of the phalangeal 
articulations, and the awkward encroachment of the distal end of the 
metacarpal bone upon the palm, the hand was quite useful. 

In September, 1864, I found in my service at the Charity Hospital 
(Blackw ell's Island), New York, an unreduced dislocation of this kind 
in a girl. The surgeons had tried to reduce it, but had failed. 

On the 25th of July, 1857, Catharine Ernst was brought to me, by 
her parents, having a dislocation of the first phalanx of the right hand, 
which had already existed some days, and upon which several unsuc- 
cessful attempts at reduction had been made. The dislocation was 
backwards, but the phalanges, instead of standing at an acute or right 
angle with each other and with the metacarpal bone, as is usually the 



FIRST PHALANX OF THE THUMB BACKWARDS. 727 

case, were in a straight line with each other and parallel with the meta- 
carpal bone. Whether this phenomenon existed from the first, or was 
due to the efforts already made at reduction, I could not determine, but 
the same thing has been noticed occasionally by other surgeons. The 
first phalanx, moreover, instead of being placed directly behind the 
metacarpal bone, occupied a position upon its back a little to the radial 
side of the centre. 

During quite half an hour I made continued and varied attempts to 
reduce the bone, by extension, by forced dorsal flexion, and by pressing 
the upper end of the first phalanx in the direction of the joint while 
pressure was made against its lower end so as to bring it into dorsal 
flexion, and finally by calling to my aid the " puzzle" and chloroform, 
but all to no purpose. 

One week later I repeated these efforts, and with no better success. 
The parents peremptorily refused to allow me to cut the lateral liga- 
ments or flexor tendons, so the bone remains unreduced. 

In the following case the relative position of the bones was the same 
as in the preceding case, but the reduction was not difficult. 

Bernard Lawler, ret. 10, was admitted to Bellevue Hospital in Jan- 
uary, 1864, with a fracture of the femur and other severe injuries. 
The dislocation of the thumb was not noticed until the ninth day. The 
redaction was then easily accomplished, in presence of the class of med- 
ical students, by forced backward flexion. 

Surgical writers have recorded, from time to time, a great many cases 
in which it has been found difficult or impossible to effect reduction ; 
and it is asserted upon the authority of Bromfield, quoted by Hey, that 
the extending force has been increased to such an amount as to tear off 
the last phalanx without having succeeded in reducing the first ; but 
while surgeons have united in their testimony as to the exceeding obsti- 
nacy of a large proportion of these dislocations, they are far from being 
agreed as to the source of the difficulty. 

Sir Astley Cooper finds a sufficient explanation in the six short and 
powerful muscles which are inserted into the first and last phalanges, 
and especially in the flexors. 1 Hey be- 
lieves the resistance to be in the lateral Fig. 295. 
ligaments between which the lower end of 
the metacarpal bone escapes and becomes 
imprisoned. Ballingall, Malgaigne, Erich- 
sen, and Vidal (de Cassis) think the me- 
tacarpal bone is locked between the two 
heads of the flexer brevis, or rather be- 
tween the opposing sets of muscles which 
centre in the sesamoid bones, as a button 
is fastened into a button-hole. Pailloux, 
Lawrie, Michel, Leva, Blechy, Roser, and 
Hueter affirm that the anterior ligament, 
including a portion of the capsule, being ciove hitch. 

1 Lawrie, of Glasgow, says that Sir Astley in a conversation with him declared 
that the " sesamoid bones" were the sources of the difficulty. See Am. Journ. Med. 
Sci., vol. xxii. p. 230, with observations and experiments by Lawrie. 




728 OF FIKST PHALANGES OF THUMB AND FINGERS. 

torn from one of its attachments, falls between the joint surfaces and inter- 
poses an effectual obstacle to reduction. A case of compound disloca- 
tion is recorded, in which Esmarch saw the capsule in this position, and 
button-holed upon the distal end of the metacarpal bone. 1 Dupuytren 
ascribes the difficulty to the altered relations of the lateral ligaments, 
which are naturally parallel to the axis of the metacarpal bone, but which 
are now placed at a right angle ; to the spasm of the muscles, and to the 
shortness of the member, in consequence of which the force of extension 
has to be applied very near to the seat of the dislocation. Lisfranc 
found in an ancient luxation the tendon of the long flexor so displaced 
inwards and entangled behind the extremity of the bone as to prevent 
reduction. Esmarch met with a similar case, in which he opened the 
joint and replaced the tendon, with a satisfactory result. 2 Deville dis- 
covered in an autopsy a similar displacement of this tendon outwards. 
Wadsworth has made the same observation. 3 

The modes of reduction practised and recommended by these different 
surgeons are as diversified and irreconcilable as their views of the mech- 
anism and pathological anatomy of the accident. 

Sir Astley Cooper recommends that extension shall be made by bend- 
ing the thumb toward the palm of the hand, to relax the flexor muscles 
as much as possible, and then, by fastening a clove hitch upon the first 
phalanx, previously covered with a piece of soft leather, the extension 
is to be continued, only inclining the thumb a little inwards toward the 
palm of the hand. If these means fail after having been continued a 

Fig. 296. 




Sir Astley Cooper's method of reducing dislocations of the thumb, with pulleys. 

considerable length of time, he advises that a weight shall be suspended 
to the thumb, passing over a pulley. Finally, in the event of the fail- 
ure of this method also, Sir Astley thought that no further attempt should 
be made, and especially that no operation for the division of these parts 
is justifiable. 

Lizars and Pirrie adopt the views of Sir Astley with little or no quali- 
fication. 

Charles Bell proposed flexing the joint, employing at the same time 
pressure ; and in obstinate cases he advised subcutaneous section of the 
lateral ligaments with a small knife, a method which has since been prac- 
tised successfully by Liston, Reinhardt, Gibson, of Philadelphia, Parker, 
of New York, myself, and others. Syme and Lizars justify the practice 

1 Esmarch, Berlin. Klinische Wochensch., 1876, No. 44. ' 

2 Ibid. 

3 Wadsworth, Am. Med. Times, Feb. 13, 1864, p. 77. 



FIRST PHALANX OF THE THUMB BACKWARDS. 729 

in certain cases. In one case which has come under my notice, after 
failing to effect reduction by the usual methods, I succeeded promptly 
after cutting one lateral ligament ; and in the second case I only suc- 
ceeded after cutting both lateral ligaments. 

Roser, from his experiments upon the cadaver, concludes that the dis- 
located phalanx must first be bent forcibly backwards, or into the posi- 
tion termed by some writers dorsal flexion, so as to throw the head of the 
phalanx forwards upon the articulating surface of the metacarpal bone. 
Parker, of New York, in his notes to the American edition of Samuel 
Cooper's work, recommends the same procedure. 

Viclal (de Cassis) recommends also that the extension should be made 
first backwards, so as to increase the displacement of the first phalanx 
in this direction, and to throw forwards its articular surface in the di- 
rection of the articular surface of the metacarpal bone. 

Hueter believes that if this method fails, when combined with some 
rotation and lateral motion, no other is likely to succeed, and he then 
advises resection. He has, however, himself in all cases been able to effect 
reduction, but the difficulty has been to maintain it, owing to the inter- 
position of the capsule ; and in such cases he has reduced the dislocation 
and then applied a plaster bandage, grasping the splint and thumb with 
his hand until the plaster was hard, and leaving it undisturbed for four- 
teen days, at the end of which time he has found that the bones would 
remain in place without the aid of the splint. He believes that the inter- 
posed ligament has been in the mean while absorbed. To me it seems 
quite certain that with the capsule thus interposed, permanent anchylosis 
must be the final result, even though it might be possible to retain the dis- 
located surfaces in apposition, and that resection would be preferable. 

This method, namely, dorsal flexion, as the first and most essential 
part of the manoeuvre, seems to have met with more general approval 
than any other, and the following observations, made by the late Reuben 
D. Mussey, of Cincinnati, illustrate the general practice among Ameri- 
can surgeons at this day. 

" I tilt the dislocated phalanx up until it stands upon its articulating 
end, place both forefingers so as to hold it in that position, and at the 
same time press against the distal extremity of the metacarpal bone, 
make firm pressure with the thumbs against the base of the dislocated 
phalanx, and slide it into its place, which can generally be accomplished 
with ease. 

" More than twenty-five years ago, the chairman of this committee, 
from attention to the mechanism of the metacarpophalangeal joint of the 
thumb, convinced himself that the principal impediment to the reduction 
of the first phalanx from backward displacement is the short flexor of 
the thumb, between the two portions of which (lying close together where 
they are fastened to the sesamoid bones) the head of the metacarpal 
bone has been thrust, the contracted part or neck of this bone lying 
firmly grasped by them. Fifteen years ago, a case occurred of this dis- 
location which he could not reduce in the ordinary way. A subcutane- 
ous division of one of the heads of this muscle was made with an iris 
knife, and the reduction was accomplished with the greatest ease. 

" Last year another case occurred, in which we failed of reduction by 
47 



730 OF FIRST PHALANGES OF THUMB AND FINGERS. 

Dr. Crosby's method, which we believe to be the best, and the subcu- 
taneous division of both heads of the muscle was made, and the reduc- 
tion instantly effected. The punctures were covered with collodion, and 
the thumb supported by a splint. As the patient was intemperate, entire 
abstinence from liquor and the adoption of a light diet were enjoined. 
Neither pain nor inflammation followed, and a month afterwards the joint 
had free motion. After the intemperate and irregular habits were re- 
sumed, the joint in a few weeks was found anchylosed. In these cases, 
the knife, in the subcutaneous operation, was carried down to the meta- 
carpal bone, so far behind its head as to preclude the possibility of mis- 
taking the lateral ligaments for the muscles. The ligaments are very 
short, and inserted close to the articular surfaces, and are probably, one 
or both, ruptured in this dislocation." 1 

Dr. J. P. Batchelder, of New York, in a paper read before the New 
York Medical Association in 1856, says : "The surgeon should take 
the metacarpal portion of the dislocated thumb between the thumb and 
finger of one hand, and flex or force it as far as may be into the palm 
of the hand, for the purpose of relaxing the muscles connected with the 
proximal end of the phalanx, particularly the flexor brevis pollicis. He 
should then apply the end of the thumb of his hand against the displaced 
extremity of the dislocated phalanx, for the purpose of forcing it down- 
wards, and at the same time grasp the displaced thumb with his other 
hand, and move it forcibly backwards and forwards, as in strongly forced 
flexion and extension, the pressure against the upper extremity of the 
first phalanx being kept up. In this way the dislocated bone may be 
made to descend, so as to be almost or quite on a line with the articu- 
lating surface of the metacarpal bone, when the thumb may be forcibly 
flexed, and, if it be not reduced, as forcibly extended, and brought 
backwards to a right angle with the metacarpal bone ; when, if the down- 
ward pressure, with the thumb placed as before, directed for that purpose, 
has been continued (which thumb, by maintaining its position, acts as a 
fulcrum, as well as by its pressure), the bone will slip into its place, and 
the reduction be effected in less time than has been spent in describing 
the process." 2 

Six successive cases of treatment by this method are mentioned in the 
American Journal of Medical Sciences for April, 1858 ; one by Rick- 
ard, one by Morgan, two by Cutter, and two by Crosby. I have also 
once succeeded by the same method. 

By those who have regarded extension as an important element in the 
reduction, various instruments have been devised for the purpose of ob- 
taining a secure hold upon the dislocated member. Sir Astley Cooper, 
as we have already seen, recommended the sailor's clove hitch ; 3 Lawrie 
advises that the thumb shall be thrust into the open handle of a large 
door key ; 4 Charri&re and Luer, of Paris, have each invented forceps, so 
constructed with fenestra and straps, that when the blades are closed 
the member is held very firmly in its grasp. Richard J. Levis, of Phila- 

1 Mussey, Trans. Amer. Med. Assoc, vol. iii. 1850, p. 357. 

2 Batchelder, New York Journ. Med., May, 1856, p. 340. 

3 Op. cit., p. 561 ; also Bost. Med. and Surg. Journ., Oct. 1, 1857. 

4 Lawrie, Amer. Journ. Med. Sci., vol. xxii. p. 229. 



FIRST PHALANX OF THE THUMB BACKWARDS. 



731 



delphia, recommends " a thin strip of hard wood, about ten inches in 
length, and one inch, or rather more, in width. One end of the piece is 
perforated with six or eight holes. The opposite end is partly cut away, 
forming a projecting pin, and leaving a shoulder on each side of it. 
Towards this end of the strip, a sort of handle shape is given to it, so as 



Fig. 297. 




Levis's instrument for reduction of dislocations of fingers or the thumb. 

to insure a secure grasp to the operator. Two pieces of strong tape or 
other material, about one yard in length, are prepared. One of these 
is passed through the holes at the ends of the strip, leaving a loop on 
one side. The other tape is passed through another pair of holes, ac- 
cording as it may be a thumb or a finger to which it is to be applied, or 
varied to suit the length of the finger, leaving a similar loop. If a dis- 
located thumb is to be acted on, the second tape should be passed through 
the holes nearest the first. The ends of each separate tape are then tied 
together. 

" To apply this apparatus, the finger is passed through the loops. The 
loop nearest the first joint is then tightened by drawing on the tape, which 
is then brought along the strip to the opposite end, across one of the 
shoulders, and secured by winding it firmly around the projecting pin. 

Fig. 298. 




Levis's instrument applied to the first finger 



The other tape is tightened in a like manner, crossing the other shoulder, 
and winding around the pin in an opposite direction, when, for security, 
the ends of the tapes are finally tied together." 1 

This apparatus enables the operator to apply both extension and flexion 
or leverage in any direction. The proximal end of the phalanx may be 
lifted, or even rotated so as to allow one side of the bone to approach 
the socket before the other. 

Malgaigne describes an apparatus invented by Kirchoff, which is very 
similar to, yet not quite so complete as this of Levis. 

In the April number of the Buffalo Medical Journal, for 1847, 1 have 
described an instrument, or rather a toy, in my possession, which I sug- 



1 Levis, Amer. Journ. Med. Sci., Jan. 1857, p. 62. 



732 OF FIRST PHALANGES OF THUMB AND FINGERS. 

gested might be useful for the purpose of making extension upon dislo- 
cated fingers ; and which, as will be seen by a reference to one of the 
cases already reported in this chapter, I have since applied successfully. 
Jt is made by the Indians, and may always be obtained during the water- 
ing season, at the Indian toy-shops at Niagara Falls. The Indians call 
it a " puzzle," and know no other use for it than to fasten it upon the 
thumb or finger of some victim, and then pull him about until he begs to 
be released. 

Fig. 299. 




Indian "puzzle," employed for the reduction of dislocations in small joints. 

The " puzzle" is an elongated cone of about sixteen or eighteen inches 
in length, made of ash splittings, and braided ; the open end of the cone 
being about three-fourths of an inch in diameter, and the opposite end 
terminating in a braided cord. When applied to the finger, it is slipped 
on lightly, forming a cap to the extremity, and to half the length of the 
finger, but on traction being made from the opposite end, it fastens itself 
to the limb w T ith a most uncompromising grasp. If constructed of ap- 
propriate size and of suitable materials, it becomes the more securely 
fastened in proportion as the extension is increased ; yet, applying itself 
equally to all the surfaces, it inflicts the least possible pain and injury 
upon the limb. When we wish to remove it, we have only to cease pull- 
ing, and it drops off spontaneously. 

Dr. Holmes says that the same instrument is made by the Indians of 
Maine, and that several years ago Dr. Davis, of Portland, brought one 
to Boston, and showed it to the Society for Medical Improvement, sug- 
gesting that it might be used for the same purpose which I have recom- 
mended. 1 

Finally, in some compound dislocations it would be better not to attempt 
the reduction of the dislocation until resection has been practised. 
Samuel Cooper relates a case in which the reduction was followed by in- 
flammation and death within a week after the accident, and Norris, of 
Philadelphia, mentions an instance which came under his observation, 
where violent inflammation and tetanus followed the reduction. 2 Roux, 
Evans, Wardrop, Gooch, Sir Astley Cooper, and many other surgeons, 
have practised resection successfully in these accidents, and have added 
their testimony in favor of this mode of procedure. 

I 2. Dislocations of the First Phalanx of the Thumb Forwards. 

Up to the present moment, I have met with but two examples of this 
dislocation, while, as has been already stated, the backward dislocation 
has been seen by me ten times. 

1 Trans. Am. Med. Assoc, vol. i. p. 267. 

2 Norris, Amer. Journ. Med. Sci., vol. xxxi. p. 16. 



FIRST PHALANX OF THE THUMB FORWARDS. 733 

Horace Kneeland, of Rochester, N. Y., set. 24, dislocated the first 
phalanx of the right thumb forwards, by striking a man with his clenched 
fist; the force of the blow being received upon the back of the second 
joint of the thumb. The dislocation had existed three days when he 
called upon me, and in the mean while several attempts had been made to 
reduce the bone by simple extension. The first phalanx was in front of 
the metacarpal bone, and in the same plane ; but the last phalanx was 
slightly inclined backwards. The hand was already swollen and quite 
painful. 

Seizing the dislocated thumb in the palm of my right hand, with my 
fingers resting upon the back of the patient's hand I forced the two pha- 
langes into flexion by firm and steady pressure continued for a few 
seconds, when suddenly the bones resumed their places, and all deformity 
disappeared. 

Intense inflammation resulted, followed, after a few days, by suppu- 
ration under the palmer fascia ; and in the end the thumb was almost 
completely anchylosed. 1 

On the 24th of April, 1855, J. M. Booth, of Buffalo, set. 19, called 
at my office, having a dislocation forwards of the first phalanx, occa- 
sioned, about half an hour before, by being thrown from a horse. The 
last two phalanges were neither flexed nor extended, but straight, and 
parallel with the metacarpal bone. 

By the same manoeuvre adopted in the preceding case, but with only 
very moderate force, the dislocation was promptly reduced. 

The usual causes of this accident are falls or blows upon the thumb 
while it is flexed; and the symptoms which characterize it are, in gene- 
ral, such as we have seen in the two examples which have just been 
given. The metacarpal bone projects posteriorly, and the first phalanx 
produces a corresponding projection toward the palm ; the two phalanges 
are extended upon each other, and parallel with the metacarpal bones. 
Nelaton saw a case in which the first phalanx was flexed about 45° ; and 
in several examples it has been observed to be slightly rotated inwards. 

In the few examples of this accident which have been reported, the re- 
duction was easily accomplished ; or, at least we may say that the diffi- 
culties in the way of reduction were not so great as they are usually 
found to be in dislocations backwards. Malgaigne has been able to col- 
lect but four undoubted examples, all of which were reduced ; Lenoir 
was able to effect the reduction by moderate measures, after the bone had 
been dislocated thirty-eight days. Ward succeeded by simple exten- 
sion. 2 

Lombard, after the trial of other plans, finally succeeded by revers- 
ing the phalanx. Employing, as we have before termed it, " dorsal flex- 
ion," with extension and lateral motion; but in all, or nearly all the 
other examples, the reduction has been effected by flexing the thumb 
forcibly toward the palm ; the reverse of the method which we have seen 
preferred, especially by American surgeons, in dislocations backwards. 
My own experience also authorizes me to recommend this plan. 

1 Trans. N. Y. State Med. Soc, 1S55, p. 73. 

2 Ward, New York Med. Times, Sept. 8, 1860. 



734 OF FIRST PHALANGES OF THUMB AND FINGERS. 

§ 3. Dislocations of the First Phalanx of the Fingers. 

The index and little fingers, owing to their exposed situation, are most 
liable to these dislocations. I have met with three examples of trau- 
matic dislocations of these joints, one of which was a forward and two 
were backward luxations, and all had occurred in the index finger. 

James Nesbitt, of Buffalo, set. 11, dislocated the index finger of the 
right hand, backwards, by a fall down a flight of stairs. On the same 
day, Feb. 11, 1851, he called upon me, and I found the finger neither 
flexed nor extended, but straight and immovable. The projections occa- 
sioned by the ends of the two bones were very marked, and such as to 
render an error in the diagnosis impossible. Reduction was accomplished 
with great ease, by reversing the finger and employing moderate exten- 
sion, while at the same time the proximal extremity of the first phalanx 
was pushed toward the distal end of the metacarpal bone. In short, the 
process was the same as that which we have recommended in dislocations 
of the thumb backwards. 

Fig. 300. 




Backward dislocation of first phalanx. Eeduction by extension. 

In the second case, presented in a woman 35 years of age, at Charity 
Hospital, April 16, 1868, the dislocation was caused by her husband 
having pulled the finger violently backwards. The metacarpal bone was 
thrust through the skin on the palm of the hand. Four weeks had now 
elapsed, and the wound had healed. A few days before, the house sur- 
geon had placed her under the influence of ether and had attempted 
reduction, but had failed, and she refused to allow me to repeat the 
attempt. 

In the example of dislocation forwards, occasioned by a blow from a 
hard ball, received upon the end of the finger, the first phalanx was in a 
position of extreme extension, and the second moderately flexed. Reduc- 
tion was effected with great ease by extension in a straight line. But if 
the surgeon were to experience difficulty in the reduction, it would no 
doubt be advisable to resort to the method of extreme flexion. 

In one instance, I have seen nearly all the fingers of the left hand, and 
the thumb of the right, dislocated backwards by the contraction of the 
cicatrix after a severe burn. 



PHALANGES OF THE THUMB AND FINGERS. 735 



CHAPTEE XV. 

DISLOCATIONS OF THE SECOND AND THIRD PHALANGES OF 
THE THUMB AND FINGERS (PHALANGEAL). 

Notwithstanding slight differences in the form of the articulations 
between the thumb and fingers, and in the size and situation of the bones 
which compose the phalanges of the fingers, we are disposed, contrary to 
the practice of some other writers upon this subject, to consider all the 
dislocations to which these several joints are liable, under one section. 
Nor, indeed, after the attention which we have given to the dislocations 
at the metacarpophalangeal articulations, do we find much to add in 
relation to these accidents ; since in almost every point of view in which 
they may be considered, they have so much in common. 

The last phalanx of the thumb is, of all the phalanges, most liable to 
dislocation, and this generally takes place backwards. Very frequently, 
also, it is accompanied with such a laceration as to render it compound. 
The dislocated phalanx is usually reversed in the backward dislocation, 
and straight, or nearly so, in the forward dislocation. 

In most cases reduction may be accomplished easily by forced dorsal 
flexion in the case of the backward luxation, and by forced palmar flex- 
ion in the case of the forward dislocation. 

In the winter of 1848, a young man was brought into my clinic, who 
had met with a forward subluxation of this phalanx about one month 
before. He had fallen upon the end of his thumb, and as the accident 
was followed by a good deal of inflammation and swelling, he did not 
notice the displacement until some time afterwards. The proximal end 
of the last phalanx projected two or three lines toward the palm ; the 
finger was straight, and this joint anchylosed. I did not think the 
chance of restoring and maintaining the bone in position sufficient to 
warrant any interference, and he was dismissed with an assurance that 
after a few months it would occasion him no great inconvenience. 

Fig. 301. 




Dislocation of the second phalanx backward 



On the 2d of March, 1851, Thomas Burton, aged about twenty-two 
years, by a fall dislocated the second phalanx of the middle finger of the 
right hand, backwards. The force of the concussion was received upon 



736 PHALANGES OF THE THUMB AND FINGERS. 

the extremity of the finger. Nine hours after the accident I found the 
bones unreduced ; the finger nearly straight, or with only slight flexion 
of the second phalanx upon the first ; the third phalanx forcibly straight- 
ened upon the second ; all the joints rigid ; finger very painful and some- 
what swollen. 

By moderate extension alone, applied for a few seconds, the reduction 
was accomplished. 

James Cooper, set. 23, came to me on Sunday morning, the 14th of 
Dec. 1851, to obtain counsel in relation to his finger which had been 
dislocated the day before, but which he had himself reduced by simple 
extension made in a straight line. His own account of it was, that he 
fell upon a slippery sidewalk, striking upon the end of his ring finger 
in such a way that it seemed to double under him. On examination, he 
found the second bone dislocated inwards, or to the ulnar side, com- 
pletely, the end of the first phalanx forming a broad projection upon 
the opposite side ; the last two phalanges fell over toward the middle 
finger, but they were neither flexed nor extended. Seizing upon the 
end of the finger with his right hand and pulling forcibly, he promptly 
reduced the dislocation himself. 

The bones were now completely in place, but the joints were swollen, 
tender, and quite stiff. 

In Sept. 1851, by the politeness of Dr. Briggs, the attending surgeon, 
I was permitted to see, in the hospital of the New York State Prison, at 
Auburn, a forward dislocation of the second phalanx of the little finger 

Fig. 302. 




Dislocation of the second phalanx forwards. 

of the left hand, unreduced. The man was at the date of my examina- 
tion forty-one years old, and the dislocation had existed eighteen years ; 
having been occasioned by a fall. A surgeon in Greene Co., N. Y., 
had attempted to reduce it soon after the dislocation occurred, but had 
failed. The joint was nearly anchylosed, yet the finger was quite as 
useful for all ordinary purposes as before. 

Dislocation of the last phalanx is frequently occasioned in the game 
of base ball, by the ball being received upon the extremity of the finger. 

A young man who was studying medicine, and a private pupil of mine, 
in attempting to catch a very hard ball, received it upon the extremity 
of the middle finger of the left hand, dislocating the last phalanx forwards. 
Twenty minutes after the accident, I found the distal extremity of the 
second phalanx projecting backwards through the skin, the tendon of the 
extensor muscle being torn completely off from its point of attachment to 
the last phalanx. The last phalanx was in a position of slight dorsal 
flexion, or extreme extension. 



DISLOCATIONS OF THE THIGH. 737 

Seizing upon the extremity of the finger, I attempted to reduce the 
dislocation by direct traction, aided by pressure upon the exposed end 
of the second phalanx, but I was unable to succeed until I brought the 
last phalanx into a position of palmar flexion. 

A slight disposition to reluxation was manifested, and a gutta-percha 
splint was therefore applied ; and, to prevent inflammation, the young 
man was directed to keep it moistened with cool water lotions. Only a 
moderate amount of inflammation followed, and in a few weeks the cure 
was complete. 

Such accidents, attended with laceration of the integuments, may occa- 
sionally demand amputation, or at least resection of the projecting bone; 
but we think Mr. Miller is scarcely right when he says that compound dis- 
locations of the fingers almost always are of such severity as to demand 
amputation. I have myself met with three other cases which were reduced, 
and did well. 

In one case of simple dislocation of the last phalanx of the thumb 
backwards I have been obliged to resort to section of the lateral liga- 
ments before accomplishing the reduction. This was in the person of a 
woman admitted to Bellevue Hospital in February, 1864. The accident 
had happened seven days before, by falling and striking upon the end of 
the thumb. The position of the last phalanx was extended, that is, in a 
line with the axis of the first phalanx. She said, however, that it was 
at first " bent straight back," but that a man took hold of it and pulled 
it out. Having placed her under the influence of ether, I attempted 
reduction by forced backward flexion, but failed. I then cut the lateral 
ligaments by subcutaneous incision, and the reduction was accomplished 
with great ease. 



CHAPTEK XYI. 

DISLOCATIONS OF THE THIGH (COXO-FEMOEAL). 

The femur is especially liable to dislocation in four directions, namely, 
upwards and backwards upon the dorsum ilii, upwards and backwards 
into the ischiadic notch, downwards and forwards into the foramen thy- 
roideum, and upwards and forwards upon the pubes. 

Dislocations are occasionally met with which cannot be arranged 
properly under either of these divisions ; indeed, it is scarcely necessary 
to say that the head of the bone may be thrown in almost every direction 
from its socket, upwards, downwards, inwards, and outwards, or in either 
of the diagonals between these lines ; and that while in a vast majority 
of cases it will assume one of the positions first named, it may in a few 
exceptional examples fall short of, or much exceed, the limits assigned 
in this division. Thus, we shall have occasion hereafter to mention ex- 
amples of dislocation directly upwards, in which the head of the bone 
will be found resting upon the fossa between the upper margin of the 
acetabulum and the anterior inferior spinous process of the ilium ; or still 



738 DISLOCATIONS OF THE THIGH. 

higher, between the anterior superior and the anterior inferior spinous 
processes ; or a little to the one side or to the other of these points. Ex- 
amples will be shown of dislocations directly downwards, in which the 
head of the femur will rest upon the notch between the lower margin of 
the acetabulum and the tuber ischii ; or still lower, and actually below 
the tuberosity ; or downwards and backwards below the spine of the 
ischium, into the lower or lesser sacro-sciatic notch. The head may be 
thrust across the foramen thyroideum, and be only arrested in the peri- 
neum upon the ramus, or even beyond the ramus of the ischium and pubes ; 
it may lodge upon the anterior surface of the body of the pubes, as well 
as upon its superior edge ; it may rest against the posterior margin of 
the acetabulum, instead of rising upon the dorsum ; or it may only mount 
upon its margin, in either of the directions named. 

In regard to frequency, the four principal dislocations occur in the 
order in which we have mentioned them ; thus, of 104 dislocations of 
the hip which I have taken the pains to collate, excluding the anomalous 
or extraordinary dislocations, and which my intelligent pupil, Mr. Frank 
Hodge, has carefully analyzed, 55 were upon the dorsum ilii, 28 into 
the great ischiatic notch, 13 upon the foramen thyroideum, and 8 upon 
the pubes. Chelius and Samuel Cooper have, however, reversed the 
order of the last two varieties, arranging dislocations upon the pubes, in 
the order of frequency, before dislocations into the foramen thyroideum. 

Coxo-femoral dislocations may occur at any period of life ; a case of 
thyroid dislocation is reported in the Lancet for May 16, 1868, which 
occurred in a child six months old. One example is mentioned in the 
G-azette Medieale, of a recent dislocation upon the dorsum ilii, in a child 
eighteen months old. 1 Dr. N. Fanning, of Catskill, N. Y., informs me, 
in a letter dated June 25, 1867, that he has reduced a dislocation upon 
the dorsum ilii, on the tenth day, in a little girl eighteen months old. 
Mr. Kirby has reported, in the Dublin Medical Press for October 26, 
1842, a case of recent dislocation in the same direction, in a child of 
three years, 2 and Dr. Buchanan has seen another, at the same age, in a 
little girl; the dislocation being into the ischiatic notch. 3 Mr. Image 
communicated to the Suffolk branch of the Provincial Medical and Sur- 
gical Association the case of a boy, three and a half years old, with a 
dislocation upon the dorsum ilii. It had existed twelve days when he 
was admitted to the Suifolk Hospital in May, 1847. Mr. Image, in re- 
porting this case to the Society, remarked that he had been induced to 
lay it before them "in consequence of a charge having been urged against 
a neighboring surgeon, of pretending to reduce a dislocation of the femur 
in the dorsum ilii, in a child only four years old, that child being a 
pauper, and chargeable to the parish. It was agreed and proved by 
authorities that no such case was recorded, and therefore had not oc- 
curred, and that seven years old was the earliest period at which this 
accident had taken place." 4 

i New York Journ. Med., Nov. 1850, p. 416. 

2 Amer. Journ. Med. Sci., vol. xxxi. p. 207, Jan. 1843. 

3 London Med.-Chir. Rev., Dec. 1828, p. 251. 

4 New York Journ. Med., Sept. 1848, p. 281. 



DISLOCATIONS OF THE THIGH. 739 

J. M. Litten, of Austin, Texas, reports a case of dislocation upon the 
dorsum ilii in a girl four years old, which he reduced by manipulation. 1 
Dr. V. P. Gibney, of New York, has reported a case in a boy of four 
years, which he reduced after six weeks. 2 Dr. Alexander Thompson, 
of Onondaga, N. Y., has reported another case in an Indian boy four 
years old. The dislocation was upon the dorsum ilii, and it was reduced 
promptly, under ether, by Drs. Thompson and Dee. 3 In the January 
number for 1847 of the American Journal of Medical Sciences is re- 
ported a forward dislocation in a boy aged five years, and a dislocation 
into the ischiatic notch in a girl of the same age. Dr. A. B. Cook, of 
Louisville, Ky.,has reduced a dorsal dislocation in a boy six years old. 4 

Dr. J. C. Warren, of Boston, met with an incomplete dislocation 
toward the foramen thyroideum in a child six years old, which, having 
been displaced eight or ten weeks, he was unable to reduce. 5 Sir Ast- 
ley Cooper mentions a case in a girl seven years old. 6 I have myself 
met with two dislocations upon the dorsum ilii, which occurred at ten 
years, and one into the foramen thyroideum. 7 Norris reports a case at 
eleven years, 8 and Gibson at twelve. 9 

On the other hand, Dr. P. J. Kline, of Portsmouth, Ohio, has reported 
to me a case of dislocation of the femur in a woman aged seventy-three, 
and which thirteen years later he found unreduced ; and Gauthier has 
seen a dislocation of the hip in a woman eighty-six years of age. 10 The 
large majority, however, occur between the fifteenth and forty-fifth years 
of life. From an analysis of eighty-four cases, we have obtained the 
following results: — 

Under 15 vears ....... 15 cases. 

15 to 30 " " 32 " 

30 to 45 29 " 

45 to 60 7 " 

66 to 85 " 1 case. 

Dislocations of the hip are much more frequent in men than in 
women; owing, probably, to the greater exposure of the former to the 
accidents from which these dislocations usually result, and possibly, 
also, in some measure, to certain peculiarities in the form and structure 
of the neck of the femur in the male. Of one hundred and fifteen cases 
collected by me, one hundred and four were in males and eleven in 
females. Dr. J. K. Rodgers, of New York, mentioned, however, at a 
meeting of the New York Kappa Lambda Society, that he had seen and 
reduced four dislocations of the femur upon the dorsum ilii in females, 
and that a fifth case had recently come to his knowledge in the New 
York City Hospital. 11 

1 New York Journ. Med., March, 1852, p. 259. 

2 Airier. Journ. Med. Sci., Oct. 1879. 3 Hosp. Gaz., Nov. 15, 1879. 

4 Richmond and Louisville Med Journ., May, 1878. 

5 Boston Med. and Surg. Journ., vol. xxiv. p. 220. 

6 A. Cooper, on Disloc, Amer. ed., p. 83, Case 27. 

7 Buffalo Med. Journ., vol. viii. p. 6. Trans. New York State Med. Soc, 1855. 
My Report on Disloc. 

s Amer. Journ. Med. Sci., Feb. 1839, p. 296. 9 Gibson's Surg., vol. i. p. 389. 

10 Gauthier, Malgaigne, op. cit. p. 805. 
i' J. K. Rodgers, New York Journ. Med., July, 1839, vol. i., first ser., p. 220. 



740 DISLOCATIONS OF THE THIGH. 

Gibson mentions an example of dislocation of both thighs at the same 
moment, 1 and Schinzinger has reported a case of double dislocation, in 
which the right femur was found in the ischiatic notch, and the left 
above the pubes. 2 

§ 1. Dislocations Upwards and Backwards on the Dorsum Ilii. 

Syn. — " Upwards on the dorsum ilii ;" Sir A. Cooper, Miller, Pirrie. " Upwards 
and outward;" Boyer, Dupuytren. "Upwards and backwards upon the hack of 
the hip-bone ;" Chelius. " Iliac ;" Grerdy, Vidal (de Cassis), Malgaigne. 

Causes. — Generally they are occasioned by some violence which 
forces the thigh into a state of extreme adduction, or of adduction united 
with rotation inwards ; and especially when at the same moment the 
head of the femur is driven upwards and backwards. Thus, a disloca- 
tion upon the dorsum may result from a fall from a height, when the 
force of the concussion is received upon the outside of the knee: the 
thigh being thus converted into a lever of the first kind, whose long arm 
is outside of the margin of the acetabulum; or the dislocation may be 
occasioned by a fall upon the foot or knee, while the limb is adducted, 
by whieh the head of the femur will be at the same moment driven up- 
wards and outwards from the socket. The accident is equally liable to 
result from the fall of a heavy weight, such as a mass of earth, upon the 
back of the pelvis when the body is much bent forwards. 

The following case presents an extraordinary example of this form of 
dislocation produced by a force acting upon the thigh as a lever of the 
first kind : — 

B., of Rochester, N. Y., set. 10, fell, in Feb. 1841, from the top of 
the high bank just below the Genesee Falls, at Rochester, a distance of 
about one hundred feet. Before he reached the bottom of the preci- 
pice, he struck upon an oblique plane of ice, from which he slid gradu- 
ally down upon the surface of the river, which was then completely 
frozen over. He did not lose his consciousness in the descent, nor after 
his arrest upon the river, but began immediately to call for assistance. 
He remembers very well that when he struct the glacier, the concussion 
was received upon the right side of the right knee, and a mark of con- 
tusion at this point confirmed his statement. Dr. Ellwood, of Rochester, 
assisted by myself, reduced the dislocation within one hour after its oc- 
currence. We employed pulleys, but the reduction was accomplished 
easily in about two minutes, and without the application of much force ; 
the bone resuming its place with an audible snap. His recovery was 
rapid and complete. 3 

Pathological Anatomy. — The capsule is lacerated more or less exten- 
sively, but especially in its posterior half ; the round ligament is rup- 
tured ; some of the small external rotator muscles are generally stretched 
or torn completely asunder, the gluteus maximus, medius, and minimus 

1 Gibson's Surg., vol. i. p. 385, sixth ed. 

2 The International Surgical Record, vol. i. No. 2 ; from Wiener Med. Presse, 1880, 
No. 3 ; Centralb. f. Chir. 1880, No. 11. 

3 Trans. New York State Med. Soc, 1855, p. 76. My report on Dislocations. 



UPWARDS AND BACKWARDS ON THE DORSUM ILII. 



41 



Fig. 303. 




Dislocation upon the dorsum ilii. 



are pushed upwards and folded upon each 
other, the head of the femur resting upon 
or within the fibres of the deep muscles ; 
the triceps adductor is put upon the stretch. 

Surgeons have not been agreed as to the 
cause of the great difficulty which has 
usually been experienced in the reduction 
of this and of all other forms of coxo-fem- 
oral dislocations. While some have as- 
cribed it alone to the resistance of the 
muscles, others have with equal confidence 
ascribed the opposition to an entanglement 
of the head and neck of the bone in the 
rent capsule, or in the ligament ; and still 
others believe that the impediment ought 
to be looked for sometimes in the muscles 
and sometimes in the capsule, or in both at 
the same moment. 

SirAstley Cooper thought that the cap- 
sular ligament was generally too much 
torn to offer any impediment to reduction, 
and he refers to some dissections in con- 
firmation of this opinion. Nathan Smith 

affirmed that the chief obstacle to reduction by extension was to be found 
in the resistance offered by the glutei muscles, which, although at first 
relaxed, would soon become tense under the stimulus of the extension, 
and which, in order that the bone might resume its position, must actu- 
ally be stretched considerably beyond their normal length. 1 W. TV. 
Reid declares that the sole resistance is at first in the abductors and 
rotators, but that finally the psoas magnus, iliacus internus, and triceps 
adductor become tense when the pulleys are employed. 2 Chassaignac 
recognizes no other impediment to reduction than the contractions of the 
muscles. 3 

Dr. Fenner, of New Orleans, gives the particulars of a dissection of 
the hip of a man admitted into the Charity Hospital, who died from 
injuries received by the bursting of a steamboat boiler. His condition 
being considered hopeless, no attempt was made to reduce the disloca- 
tion. The limb was shortened one inch and a half, and the toes turned 
inwards. Extensive ecchymosis existed. On raising the glutseus maxi- 
mus and medius, the naked head of the femur was found lying on the 
dorsum ilii with the ligamentum teres hanging to it, but partially torn 
oft*. Portions of the obturator externus pyriformis, and gemelli, were 
ruptured and lacerated. The capsule was torn through one-half of its 
extent. 

Dr. Fenner now proceeded to cut away the muscles, and when all the 
external muscles about the joint had been removed the thigh could not 



1 Surgical Memoirs, by N. R. Smith, 1831. 

2 Buffalo Med. JournJ 1851. Trans. N. Y. State Med. Soc, 1852. 

3 London Med. Times and Gazette, Dec. 1865, p. 661. 



742 



DISLOCATIONS OF THE THIGH. 



be brought down ; the iliacus interims and psoas magnus were then sev- 
ered, which permitted it to descend a little, but the head could not be 
replaced ; the triceps adductor was then divided without effect. The 
ilio-femoral ligament was found tensely stretched. All the muscles 
between the pelvis and the thigh were then severed, and still it was im- 
possible to reduce the dislocation ; the head of the femur could not be 
forced back through the rent in the capsule from which it had escaped ; 
and it was not until the opening was enlarged from one-half to three- 
quarters of an inch, that the reduction was accomplished. 

Dr. Fenner infers that the capsule possesses sufficient elasticity to 
allow the small head of the femur to pass out through a lacerated open- 
ing, which might at once contract, so as to offer considerable resistance 

to its return, and that occasion- 
Fm. 304. a lly this is the true explanation 

of the difficulty in reduction. 1 
Dr. Gunn, of Ann Arbor, Michi- 
gan, after repeated experiments 
made upon the dead body, con- 
cludes that the muscles offer no 
impediment whatever to the re- 
duction, and that the " untorn 
portion of the capsular ligament, 
by binding down the head of the 
dislocated bone, prevents its ready 
return over the edge of the aceta- 
bulum to its place in the socket." 2 
Dr. Moore, of Rochester, who has 
often repeated the same experi- 
ments upon the cadaver, declares, 
also, that in attempting to reduce 
the femur by extension alone he 
has constantly observed that the 
untorn portion of the capsule of- 
fered the main resistance, and 
that reduction could not be accom- 
plished until this was more com- 
pletely broken up, 3 

Busch, of Bonn, has arrived at 
similar conclusions ;. 4 as also Pro- 
fessors Roser, Weber, and Gelle. 
Professor Von Pitha declares em- 
phatically, that upon a knowledge of the ilio-femoral ligament is based 
the correct understanding of the various forms of hip-joint dislocations. 5 




Ilio-feinoral ligament. (Bigelow.) 



1 New York Journ. Med., Sept. 1848, p. 268, from New Orleans Med. and Surg. 
ourn., July, 1848. 

2 Ibid., Nov. 1853, p. 423 et seq. 

3 Ibid., Jan. 1855. 

4 Year-Book of Med. and Surg, for 1864. Sydenham Soc. Publications ; from 
Archiv. of Clinical Surgery, vol. iv., part i., Berlin, 1863. 

5 Von Pitha's and Billroth's Surgery, vol. iv., 1865. 



UPWARDS AND BACKWARDS ON THE DORSUM ILII. 



'■43 



But probably the most complete and conclusive defence of the views 
entertained by the gentlemen just referred to has been furnished by Dr. 
Henry J. Bigelow, the Professor of Surgery in Harvard University. In 
some respects, also, his opinions are wholly original. The following is a 
brief summary of these opinions. 

The ilio-femoral ligament, called by Dr. Bigelow the Y ligament (Ber- 
tin's ligament), the internal obturator muscle, and that portion of the cap- 
sule of the joint which is immediately subjacent, are alone required to 
explain, and are chiefly responsible for, the phenomena of the four regular 
dislocations. The regular dislocations are those in which complete dis- 
ruption of the ilio-femoral ligament has not taken place. 

The irregular dislocations are those in which the ilio-femoral ligament 
has suffered complete disruption. 

In reducing either of the regular dislocations the limb must be flexed, 
in order to relax the ilio-femoral ligament ; but if other portions of the 
capsule are not sufficiently torn to admit the return of the head within 
its socket, it must be torn by circumduction of the limb. After flexion, 
and perhaps circumduction, the reduction may be completed by rotation, 
or by extension of the thigh at right angles with the anterior surface of 
the body. 

The dorsal dislocation owes its. inversion to the external fasciculus of 



the ilio-femoral ligament. 



Fig. 305. 




Dislocation upon the dorsum ilii. (Bigelow.) 



In the ischiatic dislocation, "dorsal below the tendon" (Bigelow), the 
head is arrested, in extension, by the tendon of the obturator and the 
subjacent capsule. 



744 



DISLOCATIONS OF THE THIGH. 



The flexion and eversion of the limb in the thyroid dislocation are due 
to the ilio-femoral ligament. 

In the pubic dislocation the ascent of the limb is finally arrested by 
the ilio-femoral ligament. 

The conclusion' at which we ought to arrive seems to be that, in some 
cases, the capsule being completely or almost completely torn away, the 
muscles offer the only resistance ; and that according to the exact position 
of the limb or degree of displacement, one or another set of muscular 
fibres will oppose the reduction ; and in other cases, the muscles being 
paralyzed by the shock, or by anaesthetics, the partially torn capsule, into 
which the head of the bone is received as in a button-hole, or the Y liga- 
ment, prevents its free return into the socket. 

Symptoms. — Sir Astley Cooper affirmed that the limb was sometimes 
found shortened in this dislocation to the extent of three inches. Liston, 

B. Cooper, Gibson, and others, re- 
Fig. 306. peat the affirmation. Chelius places 

the extreme of shortening at two and 
a half inches ; Miller, at two inches ; 
while Malfiraigne declares that he has 
never seen the limb shortened more 
than half an inch, and that in some 
cases it is not shortened at all, and 
the very opposite opinions enter- 
tained by other surgeons he attrib- 
utes to errors in the measurement. 
I am certain, however, that Mal- 
gaigne has fallen into some error, 
and that, while the average short- 
ening is about one inch or one inch 
and a half, it does occasionally reach 
three inches. 

The thigh is rotated inwards, ad- 
ducted, and slightly flexed upon the 
pelvis. The great toe of the dislo- 
cated limb, when the patient stands 
erect (and in this position the exami- 
nation ought, if possible, to be made), 
rests upon the instep of the foot of 
the sound limb, and the knee touches 
tho opposite thigh near the upper 
margin of the patella. It must not 
be supposed, however, that the posi- 
tion of the limb is in all cases pre- 
cisely such as we have described. 
Indeed the degree of rotation, ad- 
duction, flexion, etc., will vary ac- 
cording as the head of the femur is 
more or less displaced, the capsule, 
including the ligaments, more or less torn, or as it may be torn in its 
upper or lower margins, as the muscles may be actually rent asunder or 




Dislocation upon the dorsum ilii. 



UPWARDS AND BACKWARDS ON THE DORSUM ILII. 745 

only put upon the stretch, and perhaps also according to the amount of 
injury and consequent relaxation which they may have sustained from 
the shock. The thigh can be easily flexed ; adduction is more difficult, 
but abduction is almost impossible, except to a very limited extent: the 
body of the patient is a little bent forwards, the roundness of the hip is 
lost in consequence of the relaxation of the glutei muscles ; the tro- 
chanter major is depressed, and approaches the anterior superior spinous 
process of the ilium ; and if the patient is not fat, and swelling has not 
already taken place, the head of the femur may be felt in its new posi- 
tion rotating under the hand when the limb is turned inwards or out- 
wards, but especially may it be felt when, by flexing or extending the 
limb, the head is made to move downwards and upwards, upon the dor- 
sum ilii. 

As we have already said, this examination ought to be made, if possi- 
ble, in the erect posture ; after which, it will be well to place the patient 
alternately upon his back, upon his sound side, and upon his belly, until 
the diagnosis is rendered complete. 

The differential diagnosis between dislocation upon the dorsum ilii and 
a fracture of the neck of the femur may be briefly stated as follows. 

In fracture, we may expect to find crepitus ; the limb is in most cases 
mobile ; the toes are generally turned out ; the limb is shortened moder- 
ately or not at all ; the patient is sometimes able to walk for a short dis- 
tance ; fractures of the neck of the femur generally occur in advanced 
life. 

In dislocation, crepitus is not often present, and only w T hen a fracture 
coexists ; the limb is immobile, or nearly so ; the toes are turned in ; the 
limb is shortened more : the patient is unable to bear the weight of his 
body upon his foot for one moment. Skey, however, says he has seen a 
patient with a recent dislocation, who walked one-quarter of a mile, to 
the hospital. I do not think that any other similar case is upon record. 
Dislocations of the femur generally occur in middle life. 

I have been frequently told by persons who have called upon me with 
children suffering under hip-disease, that they had been informed the hip 
was out, and they expected me to reduce it. In two or three instances 
they have blamed their surgeons very much, because they had not de- 
tected the accident at the time of its occurrence. Norris, of Philadel- 
phia, mentions an extraordinary example of this kind, as having been 
presented at the Pennsylvania Hospital, and which ought to serve as a 
sufficient warning to prevent similar mistakes in future. A lad, twelve 
years old, was brought to the hospital from a neighboring State, who a 
short time previous had been suddenly attacked with lameness in his right 
limb, and which, by his friends, was attributed to some injury received in 
play. Two physicians, who had been called to see the boy, pronounced 
him to be laboring under dislocation of the hip, and had made two strong 
efforts with the pulleys, to reduce it ; but, after causing great suffering, 
they gave up all hopes of ever replacing the bone, and sent him to Phila- 
delphia. The symptoms were plainly those of hip-joint disease in its 
early stage. The attitude was that assumed by those laboring under 
this affection ; the leg seemed lengthened, but a careful measurement 
showed that it was of the same length with the other ; the buttock was 
48 



746 



DISLOCATIONS OF THE THIGH. 



Fig. 307. flattened, and the motions of the joint were 

tolerably free but painful. 1 

If the supposed dislocation occurs in a 
child, or in a person under ten years of age, 
we ought to take especial pains to ascertain 
that it is not a separation of the epiphysis, of 
which accident we have mentioned some ex- 
amples when speaking of fractures of the 
neck of the femur. 

Examples have occasionally been reported 
of " everted dorsal dislocations," in which 
most of the usual signs of a dorsal dislocation 
are present, except that the limb is everted, 
and sometimes slightly abducted. Bigelow 
attributes this condition to a rupture of the 
outer fibres of the ilio-femoral ligament, and 
he affirms that under these circumstances the 
limb may be found inverted, but it is also 
easily everted; the foot may be slightly 
everted, it may lie flat upon the bed, or it 
may even point backwards. 

The treatment of the everted dorsal dislo- 
cation consists in reducing it first to an ordi- 
nary dorsal dislocation by flexion and rotation 
inwards, aided by adduction, if necessary. 

Prognosis. — Boyer says the limb remains 
always weaker than the other, the round liga- 
ment never uniting completely ; and that in- 
flammation of the cartilages and synovial glands may ensue, ending in 
caries of the joint. Such results have, indeed, been occasionally met with, 
nor are examples wanting in which more rapid inflammation, resulting 
in the formation of acute abscesses, has followed, but these are only rare 
accidents. In the large majority of cases the patients recover speedily, 
and in the course of a few weeks, or months at most, the limb seems to 
be as sound and as useful as before. 

In one case reported from my clinic at Bellevue, the patient, aged 33, 
after I had reduced a recent dorsal dislocation by manipulation, walked 
on the fourth day ; and on the seventh day he ascended five flights of 
stairs to the amphitheatre, walking without any halt. He declared, also, 
that he felt no soreness or lameness about the hip. 2 

Examples of non-reduction, however, from an error of diagnosis, or, 
what is more pertinent to our present purpose, from a failure to accom- 
plish the reduction where the attempt has been made, are numerous. 
Fortunately, Mr. Chelius, the author of a most excellent System of 
Surgery, to which we have already had frequent occasion to refer, has 
sufficient reputation, the world over, to enable him to bear a portion of 




Everted dorsal dislocation. 
(Bigelow.) 



1 Norris, Amer. Journ. Med. Sci., vol. xxv. p. 280. 

2 Reduction of a Dorsal Dislocation of the Femur. " The Med. Record," Dec. 3, 1876, 
p. 780 



UPWARDS AND BACKWARDS ON THE DORSUM ILII. 747 

these failures, without injury to himself or to the profession which he so 
eminently adorns. We shall therefore make no apology for reporting 
the following unsuccessful attempt to reduce a dislocation of the hip in 
which Mr. Chelius himself was the operator. 

On the 11th of June, 1851, John Mauren, a German, get. 19, called 
at my office and related as follows : " When ten years old, I fell from a 
tree, a height of six feet, and dislocated my left hip. I was then living 
twelve miles from Heidelberg, and I was immediately taken there, but 
I did not see Mr. Chelius until the next morning. He took me to the 
University, and, before the medical class, attempted to reduce it, but he 
could not. During several weeks following, he tried six times, using 
pulleys, etc., but he could never succeed." 

On examination, I found the limb shortened two inches, the head of 
the femur lying upon the dorsum ilii ; the knee was turned in, but the 
toes were inclined a little outwards. He was able to walk rapidly, of 
course with a manifest halt, yet without pain or discomfort. 

Treatment. — Regarding dislocations of the femur upon the dorsum 
ilii as the type of all the coxo-femoral dislocations, the remarks which 
we shall make under this section may be considered applicable, with 
only certain qualifications, to all the others. 

We shall arrange the various methods of reduction which have been 
employed by surgeons, under two principal heads, namely, manipulation 
and extension. It is not possible, however, to classify rigidly the dif- 
ferent procedures, so as to bring them under these two simple divisions, 
without some violence ; since neither manipulation nor extension has 
usually been employed alone, but almost always some degree of exten- 
sion has been recommended in connection with the manipulation ; if not 
in the first instance, at least in the event of the failure of manipulation 
alone ; while, on the other hand, extension is seldom if ever practised 
without manipulation. We intend, then, to imply by these designations 
respectively, that either manipulation or extension has constituted the 
prevailing feature in the treatment. 

Reduction by manipulation dates from the earliest records of our 
science. Says Hippocrates : " In some the thigh is reduced with no 
preparation, with slight extension directed by the hands, and with slight 
movement ; and in some the reduction is effected by bending the limb 
at the joint and making rotation." 1 

Richard Wiseman, who wrote in 1676, speaks as follows: "If the 
thigh-bone be luxated inwards, and the patient young and of a tender 
constitution, it may be reduced by the hand of the chirurgeon, viz., he 
must lay one hand on the thigh, and the other on the patient's leg, and 
having somewhat extended it toward the sound leg, he must suddenly 
force the knee up toward the belly, and press back the head of the 
femur into its acetabulum, and it will snap in. For there is no need 
of so great extension in this kind of luxation ; for the most considerable 
muscles being upon the stretch, the bowing of the knee as aforesaid 
reduceth it ; yet in rough bodies it may require stronger extension." 2 

1 Works of Hippocrates, Syd. ed., vol. ii. p. 643. 

2 Eight Chirurgical Treatises. By Richard Wiseman, Serjeant-Chirurgeon to King 
Charles II. London, 1676. Book vii. chap. viii. 



748 DISLOCATIONS OF THE THIGH. 

Richard Boulton repeated, in 1713, almost the same instructions, 
affirming that this plan was applicable especially to dislocations inwards, 
in the case of " young and tender children." 1 

In 1742 Daniel Turner declared that he had reduced three disloca- 
tions of the hip, one of which was a backward dislocation, by a method 
combining extension with manipulation, but alone " by the strength of the 
arm or without any other instrument." Extension and counter-exten- 
sion being made by assistants, and " as soon as the surgeon perceives 
the bone moving out," says Turner, "let him take his opportunity, giv- 
ing orders to the extenders below suddenly to lift up the patient's thigh 
toward his belly, pressing with his hands, either to the right or left, as 
the situation of the same requires, and therewith force back its head to- 
ward the acetabulum, whereunto it will, nipping over the tip of the car- 
tilage, snap sometimes with a loud noise." 2 

Thomas Anderson, surgeon, of Leith, in Scotland, was called, in Sept. 
1772, to see a man who had dislocated his left femur into the foramen 
thyroideum. When he arrived four other surgeons were present, and 
prepared to use the pulleys, which they did in his presence several times, 
but to no purpose. After examining the limb carefully, " I was con- 
vinced," says Mr. Anderson, " that attempting the reduction in the com- 
mon method, with the thigh extended, was improper, as the muscles were 
all put on the stretch, the action of which is, perhaps, sufficient to over- 
balance any extension we can apply. But by bringing the thigh to near 
a right angle with the trunk, by which the muscles would be greatly re- 
laxed, I imagined that the reduction might more readily take place, and 
with much less extension. 

"When I made this examination, he was lying on a table on his back. 
I raised the thigh to about a right angle with the trunk, and, with my 
right hand at the ham, laid hold of the thigh, and made what extension 
I could. From this trial I found I could dislodge the head of the bone. 
At the same time that I did this, with my left hand at the head and 
inside of the thigh, I pressed it toward the acetabulum, while my right 
gave the femur a little circular turn, so as to bring the rotula inwards 
to its natural situation ; and on the second attempt it went in with a 
snap observable to the gentlemen standing around, but more so to the 
poor man, who instantly cried out he was well and free from pain. His 
knees could then be brought together; the legs were of the same length, 
and the foot in its natural situation. The knees were kept together for 
some time, with a roller, to confine the motion of the thigh; and in three 
weeks he was at his work, without the least stiffness in the joint." 

Subsequently Mr. Anderson reduced by a similar method a dislocation 
upon the dorsum ilii in a child eight years old, and which had been out 
nineteen days. 3 

Says Pouteau, in a memoir on dislocations of the thigh upwards and 
outwards: "We observe then, first, that the thigh ought to be flexed to 

1 A System of Rational and Practical Surgery. By Richard Boulton. London, 1713, 
p. 346. 

2 The Art of Surgery. By Daniel Turner. London, 1742, vol. ii. p. 339. 

3 Anderson, Medical Commentaries, Edinburgh, 1776, vol. ii. pp. 261-4. 



UPWARDS AND BACKWARDS ON THE DORSUM ILII. 749 

a right angle with the body during the extension and counter-extension ; 
second, that we ought to rotate the thigh from within outwards, when 
the extension appears to be sufficient; third, that this position puts into 
relaxation, as much as possible, the triceps and gluteal muscles, which 
oppose the chief resistance to the extension, thus saving the patient from 
excessive pain; fourth, that the flexion of the thigh places the head of 
the bone in the best position for a return to the cotyloid cavity during 
extension; fifth, that feeble extension suffices for reduction, because all 
of the muscles of the thigh are relaxed." 1 

On the 7th of January, 1811, Dr. Philip Syng Physick, of Phila- 
delphia, reduced an outward dislocation of the hip, after extension had 
failed, by flexing the thigh to a right angle with the body, and then 
giving to the limb an " outward circular sweep." 2 

So early as 1815, and perhaps much earlier, Nathan Smith, Professor 
of Surgery in the New Haven Medical College, taught that the only 
correct mode of reducing a dislocation upon the ilium was to flex the 
leg upon the thigh, the thigh upon the pelvis, and then to carry the limb 
diagonally to the opposite side, from whence it was to be brought out- 
wards and downwards; 3 and in 1821, Dr. Smith, being under oath, 
affirmed as follows: "I do not think that the mechanical powers, such 
as the wheel and axle, or the pulleys, are necessary to reduce a dislo- 
cated hip, or any other dislocation." He further adds that he once 
reduced a dislocation upon the dorsum ilii after he had pulled in every 
direction but the right, " by carrying the knee towards the patient's 
face." 4 Subsequently the son of Dr. Smith, Nathan R. Smith, the 
present distinguished teacher of surgery in the Medical College at Balti- 
more, gave a more full account of his father's method, illustrating his 
views of the pathology of these dislocations, and the mechanism of their 
reduction, by several drawings. It must be noticed, however, that Dr. 
Nathan Smith left no written explanation of his views and practice, except 
that which is to be found in the affidavit already quoted, and that the 
account published by his son is from memory, and it is given as follows : 
"The patient, being prepared for the operation by whatever means may 
be deemed necessary, may be placed in an attitude convenient for the 
operation, with the body securely fixed, by placing him in the horizontal 
posture, on a narrow table covered with blankets, and on the sound side. 
To the table his body should be firmly fixed, and this can be conveniently 
done by folding a sheet several times, lengthways — then applying the 
middle of the broad band thus made to the inner and upper part of the 
sound thigh — carrying its extremities under the table, crossing them 
beneath it, and then carrying them obliquely up and crossing them firmly 
over the trunk, above the injured hip. The ends may then be secured 
beneath the table. To support the trunk the more firmly, a pillow may 
be placed on each side of it upon the table, and be included in the band- 

1 Vidal (de Cassis) ; from (Euvres posthumes de Pouteau, Paris, 1783. 

2 Physick, Dorsey's Surg., 1813, vol. i. p. 242. Mem. of Nathan Smith, 1831, p. 
172. Phelps's paper in Trans. New York State Med. Soc, 1856, p. 169. 

3 Trans. N. H. State Med. Soc, 1854, p. 55. 

4 Report of the Trial of an Action for Malpractice. Lowel v. Faxon and Hawks, 
Machias, Maine, 1824; also Buff. Med. Jour., vol. xiii. p. 515. 



750 DISLOCATIONS OF THE THIGH. 

age. Should the operator design to employ any degree of extension, a 
counter-extending band may be placed in the perineum, and carried up 
to the extremity of the table, be fixed to some more firm body, or held 
by the hands of assistants. 

" The operator, now standing on the side to which the patient's back 
presents, grasps the knee of the dislocated member with his right hand 
(if the left femur be dislocated — vice versa, if the right), and the ankle 
with the left. The first effort which he makes is to flex the leg upon 
the thigh, in order to make the leg a lever with which he may operate 
on the thigh-bone. The next movement is a gentle rotation of the thigh 
outwards, by inclining the foot toward the ground, and rotating the knee 
outwards. Next the thigh is to be slightly abducted by pressing the 
knee directly outwards. Lastly, the surgeon freely flexes the thigh 
upon the pelvis by thrusting the knee upwards toward the face of the 
patient, and at the same moment the abduction is to be increased. 

" Professor N. Smith regarded the free flexion of the thigh upon the 
pelvis as a very important part of the compound movement. He believed 
that it threw the head of the bone downwards, behind the acetabulum, 
where the margin of the cup is less prominent, and over which, therefore, 
the abductor muscles would drag it with less difficulty into its place. 

u The operator may slightly vary these movements, as he increases 
them, so as to give some degree of rocking motion to the head of the os 
femoris, which will thereby be disengaged with the more facility from 
its confined situation among the muscles." 1 

Dr. Luke Howe, of Boston, who was a pupil of Nathan Smith's, gives 
the following account of the method practised by him successfully, about 
the year 1820, and which method, he says, was recommended by his 
preceptor : " The patient was permitted to lie on his back on the bed 
where I found him, the knee of the luxated limb turned in and over the 
other. I raised the knee in the direction it inclined to take, which was 
toward the breast of the opposite side, till the descent of the head of the 
bone gave an inclination of the knee outwards, when I made use of the 
leg, being at right angle with the thigh, as a lever to rotate the latter 
and turn the head of it inwards. It then readily returned to its socket, 
with an audible snap. During this operation, the two assistants who 
had been placed to make the lateral extension and counter-extension, if 
ultimately required, were directed to draw moderately at their towels. 
How much of the success of the operation is to be imputed to their ex- 
tension, and the rotation of the thigh by the leg, I am unable to deter- 
mine ; but as Dr. Smith succeeded without the aid of either, and as the 
head of the femur seemed to descend by an easy and natural process, I 
am inclined to believe that all that is necessary, in such cases, is to ele- 
vate the knee, when the ilium, the muscles attached to it, and perhaps 
the ligament, become the natural fulcrum, over which the thigh, as a 
lever, acts to bring the head down and inwards into the socket." 2 

1 Medical and Surgical Memoirs, by Nathan Smith, late Prof, of Surgery, etc., in 
Yale College. Edited by Nathan R. Smith, Professor of Surgery in Univ. of Mary- 
land. Baltimore, 1831, pp. 163-183. 

2 Howe, Boston Med. and Surg. Journ., vol. xxii. p. 249, May, 1840. 



UPWARDS AND BACKWARDS ON THE DORSUM ILII. 751 

Kluge, in 1825, combined moderate extension with manipulation, by 
flexing both the leg and thigh, while at the same moment the thigh was 
abducted and the knee rotated inwards. 1 Wathman, in 1826, directed 
that in this dislocation the limb should be seized by the knee and ankle 

Fig. 308. 




Nathan Smith's method of reduction by manipulation. (From Smith's " Memoirs.") 

and slowly lifted forwards until it came to a right angle with the long 
axis of the body ; when, if the outward " self-twisting of the thigh" 
occurs, " which cannot be prevented by fast holding," the movement of 
the head of the bone is declared, and it will only remain for the surgeon 
to let down the thigh gradually upon the bed so that the two limbs will 
come side by side, and the reduction will be accomplished. 2 

Rust recommended also, in 1826, a similar plan, combining moderate 
extension by the hands, with flexion and abduction of the thigh. 3 

Colombat, whose opinions date from 1830, suggested that the patient 
should lay himself forwards upon a bed or table, no higher than his 
hips, with the sound leg and foot resting upon the floor, and that then 
the surgeon seizing the foot with one hand, so as to flex the leg, should, 
with the other hand, exercise a moderate degree of extension, and at the 
same time move the limb to the right or to the left, backwards and for- 
wards, in order to disengage the head of the femur ; and, finally, that 
he should communicate to the thigh a sudden movement of circular rota- 



1 Chelius's Surg., by South., Amer. ed., vol. ii. p. 241. 
3 Ibid., p. 241, note by South. 



2 Ibid., p. 239. 



752 DISLOCATIONS OF THE THIGH. 

tion, either from within outwards, or from without inwards, as the sur- 
geon may choose. 1 

Collin states that, in 1833, he had reduced four dislocations of the 
hip by a method very similar to this recommended by Colombat. 2 

Dr. William Ingalls, of Chelsea, Mass., reduced a compound disloca- 
tion of the femur, in which the head of the bone rested upon the pubes, 
after an unsuccessful attempt had been made to reduce it by extension. 
" An assistant, taking the ankle of the dislocated limb in his right hand, 
and placing his left in the ham, bent the leg at right angles upon the 
thigh, and the thigh upon the pelvis, then lifting with a power little 
more than sufficient to elevate the whole limb, he carried it to its greatest 
state of abduction, at the same time rotating the femur inwards, while 
Dr. Ingalls passed his thumb through the wound, and pressing upon the 
head of the femur, directed it toward the acetabulum. At this moment 
he directed the limb to be forced toward its fellow, by which the reduc- 
tion was eifected with the greatest possible ease and elegance." 3 

Similar methods of reduction, with only such slight variations as 
scarcely deserve a special notice, have been suggested and practised 
from time to time by Palletta, in 1818 ; 4 Desprez, in 1835 ; 5 Vial, in 
1841 ; 6 Fischer, Mahr, and Clark, in 18 19. 7 

In 1851 Dr. W. W. Reid, of Rochester, N. Y., published an account 
of the method practised by himself successfully in three cases of dislo- 
cation upon the dorsum ilii, the first of which dated from the year 1844. 
His method, as applied to a dislocation upon the dorsum ilii, consists in 
" flexing the leg upon the thigh, carrying the thigh over the sound one, 
upwards over the pelvis as high as the umbilicus, and then abducting and 
rotating it." 8 

Dr. Markoe, of New York, adopts the same procedure, except that 
when the limb has been sufficiently flexed and abducted, he directs that 
the limb shall' be gradually brought down, and he affirms that it is during 
this last manoeuvre that he has usually found the bone resume its place 
in the socket. 9 

Bigelow, of Boston, declares, as has already been stated, that in all 
the regular dislocations, that is to say, in all those dislocations in which 
the ilio-femoral ligament is not torn, the thigh must be first flexed, in 
order to relax this ligament, and then reduction may be effected by ex- 
tension directly forwards, the thigh being at a right angle with the body, 
or by rotation. In some cases, where there is probably only a button- 
hole slit in the capsule, free circumduction may be required in order that 
the capsule may be torn more freely. 

His method of reducing the dislocation upon the dorsum ilii, is to flex 
the thigh upon the abdomen, abduct and then rotate outwards ; or, to 
flex, then adduct and rotate a little inwards, to disengage the head of the 

i Malgaigne, op. cit., vol. ii. p. 825. 2 Ibid., p. 823. 

3 Ingalls, Bransby Cooper's ed. of Sir Astley's English ed., 1842, and Amer ed., 
1852. 

4 Chelius's Surg. ; note by South. 5 Malgaigne. 6 Ibid. 

7 Dublin Med. Press, Dec. 3, 1851. New York Journ. Med., March, 1852. 

8 Reid, Buffalo Med. Journ., vol. vii. Aug. 1851, pp. 129-143. 

9 Markoe, New York Journ. Med., January, 1855. 



UPWARDS AND BACKWARDS ON THE DORSUM ILII 



753 



bone from behind the socket, then abduct and pull directly upwards. 
When necessary, circumduction is practised to lacerate the capsule more 
completely. 



Fig. 309. 




Kelaxation of the iliofemoral ligament by flexion. (Bigelow.) 

Reduction by extension dates from a period equally early with reduc- 
tion by manipulation. Hippocrates recommended, when other and gentler 
means had failed, to make extension and counter-extension ; the extend- 
ing bands being made fast above the knee and above the ankle, so as to 
distribute the points of pressure ; and the counter-extending bands being- 
secured around the chest under the armpits, and also, if thought neces- 
sary, in the perineum of the sound side. 

Fig. 310. 




*>s 



Hippocrates's mode of reducing dislocations of the hip by extension. 

Among the methods recommended and practised by Hippocrates, was 
sitting across the upper round of a ladder with a weight attached to the 
thigh of the dislocated limb; or suspending the patient from a sort of 



754 DISLOCATIONS OF THE THIGH. 

gallows with the head downwards, and if the weight of the patient's own 
body proved insufficient, the surgeon might add his also ; a method which 
Hippocrates characterizes as " a good, proper, and natural mode of re- 
duction, and one which has something of display in it, if any one takes 
delight in such ostentatious modes of procedure." 1 

With various modifications as to the position of the limb, and as to the 
points upon which the extending and counter-extending forces are to be 
applied, and with differently constructed appliances, surgeons have con- 
tinued to employ extension down to this day. 

The great majority have regarded flexion of the thigh as essential to 
success ; some holding the limb only slightly flexed, and others insisting 
that flexion should be increased to a right angle with the body. 

The French surgeons, including Boyer and Vidal (de Cassis), prefer 
generally to apply the extending bands to the feet, in order that the 
muscles of the thigh may not be stimulated to contraction by the pres- 
sure of the bandages. Mr. Skey adopts the same method. 

Sir Astley Cooper, Samuel Cooper, B. Cooper, Fergusson, Miller, 
Pirrie, Erichsen, aud the English surgeons generally, make fast the lacq 
above the knee. J. L. Petit and Duverney, among the French, and 
Dorsey, Gibson, with most of the American surgeons, recommend the 
same ; but Gerdy seeks to multiply the points of application, and for this 
purpose secures the extending band to the whole length of the leg, and 
to a small portion of the thigh above the knee. 

The counter-extending bands are now almost universally made to ope- 
rate against the perineum of the dislocated limb, but Roux, following the 
practice of Hippocrates, places it in the perineum of the sound limb. 
Gibson recommends the same practice. 

Lizars recommends that sometimes the reduction should be attempted 
by simply placing the heel in the perineum and making the extension 
with the hands, very much as Sir Astley Cooper advises us to proceed 
in dislocations of the humerus. Morgan and Cock, of Guy's Hospital, 
have reduced six cases of dislocation of the hip-joint by placing the foot 
between the thighs, so that it pressed against the upper part of the dis- 
located bone, and thrust it aAvay from the pelvis ; extension and rotation 
of the limb being made at the same time by assistants. 2 Three of these 
were examples of dislocation upon the dorsum ilii, two upon the pubes, 
and one into the foramen thyroideum ; and most of them had occurred 
in weak or elderly persons. 

Ambrose Pare* was among the first to recommend the use of pulleys 
for the reduction of dislocations. Most surgeons since his day have em- 
ployed them for the purpose of making extension more energetic and 
steady, and that it might be longer continued. Sir Astley Cooper's plan 
of procedure is as follows : — 

The patient having been bled freely, and the muscles still farther 
relaxed by nauseating doses of antimony and by the hot bath, he is to be 
placed on his back upon a table of convenient height between two sta- 
ples ; a strong padded leathern girth or perineal band, constructed so as 

1 Works of Hippocrates, Syd. ed., London, vol. ii. p. 641. 

2 Cock and Morgan, Chelius, op. cit., vol. ii. p. 242, note by South. 



UPWARDS AND BACKWARDS ON" THE DORSUM ILII. 755 

to receive the thigh, and to press at the same moment against the peri 
neum and the outer surface of the pelvis, is then applied and made fast 
to one of the staples situated behind the patient in the direction of the 
axis of the limb. A wetted linen roller is next to be tightly applied 

Fig. 311. 




Reduction of a dislocation on the dorsum ilii, by pulleys. (Sir Astley Cooper's method.) 

just above the knee, and upon this a leathern strap is to be buckled, 
having two short straps with rings at right angles with the circular part ; 
or, instead of this, a round towel made in the knot called the clove-hitch. 
The knee is to be slightly bent, but not quite to a right angle, and 
brought across the opposite thigh a little above the knee. The pulleys 
being now attached, the extension is to be commenced. 

A very simple and efficient mode of making the extension, if one has 
not the pulleys, is to employ for this purpose a small rope, the ends being 



Fig. 312. 




Eeduction of a dislocation on the dorsum ilii, by the Spanish windlass. (Gilbert.) 

tied together, and the rope being then doubled upon itself once or twice, 
so as to make four or eight parallel cords. The opposite ends of this 
bundle of ropes being made fast to the limb and the staple, the extension 
is made by thrusting a stick through its centre and twisting it. (Fig. C12.) 



756 



DISLOCATIONS OF THE THIGH 



I have several times had occasion to resort to this plan ; and indeed 
it has been for some time known and practised among surgeons in this 
country, 1 having been first, according to Professor Gilbert, introduced 
by Fahnestock, of Pittsburg, Pa. It is usually known as the " Spanish 
windlass." 

Jarvis's adjuster, to which I have already made allusion when speak- 
ing of dislocations of the humerus, has been often used with success in 
dislocation of the hip as well as in dislocations of the shoulder. 2 Its 
power is equal to that of the pulleys, while the direction of the force can 
be varied with much greater ease. The most serious objections to the 
instrument, .as employed for the reduction of dislocations, are its com- 
plexity and expensiveness. 

Fig. 313. 




Jarvis's adjuster applied for reduction of a dislocation of the hip. 

Mr. Fergusson says that the Lancet for July 26, 1845, contains a 
description of a similar apparatus constructed by Coxeter at the sugges- 
tion of G. N. Epps ; 3 and L'Estrange, of Dublin, has invented a " wind- 
lass" for making extension, with a "forceps," by which the extending 
power can be instantly disengaged. 4 Mr. Bloxham's " dislocation tour- 
niquet" is also very simple, and Mr. Erichsen affirms that by it "any 
amount of extending force that may be required can be readily set up 
and maintained." 5 Sedillot, a French surgeon, has suggested that when 
pulleys are used, we should measure the exact power employed in the 



1 Gilbert, of Philadelphia, note to Pirrie's Surg. ; also Amer. Journ. Med. Sci., vol. 
xxxv. April, 1845. 

2 Crandall, Bost. Med. and Surg. Journ., vol. xxxix. p. 77; Atlee, Trans. Amer. 
Med. Assoc, vol. iii., 1850, p. 357. 

3 Fergusson, 4th Amer. ed., p. 200. * Ibid., p. 198. 
5 Erichsen, Amer. ed., 1858, p. 242. 



UPWARDS AND BACKWARDS ON THE DORSUM ILII. 757 

reduction, by an ingeniously contrived apparatus called the dynanome- 
ter. 1 Such an instrument might occasionally be useful in preventing the 
application of excessive force, especially when the patient is under the 
influence of an anaesthetic. 

Fig. 314. 



Bloxham's " dislocation tourniquet" applied for reduction of a dislocation on the pubes. 

Appreciation. — Finally, without attempting to determine the precise 
relative value of these different procedures, all of which claim for them- 
selves the testimony of experience, we are prepared to admit that no one 
of them is without merit, and that each may in certain cases possess ad- 
vantages over the others. Precisely what the cases are to which each 
individual method may be especially applicable, we believe it would be 
impossible to declare unless the cases were actually before us ; and even 
then it would probably be found difficult often to say which was the best 
until a fair trial of one or more, and a final success, had determined the 
question. The time has not yet arrived in which we may institute a 
rigid comparison between the relative merits of the two leading plans of 
reduction, manipulation and extension, for while it is true that reduction 
by manipulation has been practised from the earliest day, it is equally 
true that extension has been generally preferred and practised by sur- 
geons in all ages. Indeed, it was not until Dr. Reid, of Rochester, 
again called the attention of the profession to this subject, illustrating 
his views by the results of several successful experiments and by inge- 
nious arguments, that reduction by manipulation could be said to have 
been fairly introduced as an established method of practice ; a large 
majority of all the cases upon record of reduction by manipulation 
having been reported since the year 1851, the period of Dr. Reid's first 
communication to the Buffalo Medical Journal. 

The following summary of a paper prepared by myself, with the view 
of determining, if possible, the relative value of the two methods, and 
exhibiting an analysis of sixty-four cases in which manipulation was 
employed, will enable the reader to form some estimate of the difficulty 
in which this subject is involved : and if it does not actually decide a 

1 Amer. Jouri:. Med. Sci., vol. xv. p. 530. 



758 DISLOCATIONS OF THE THIGH. 

moot-point, it will at least demonstrate that the method by manipulation 
is not without its hazards. 1 

" Of forty-one cases in which the fact is stated, twenty-eight were 
reduced on the first attempt, seven on the second, four on the third, and 
two on the seventh. In seven examples the head of the femur has been 
thrown from one position to another upon the pelvis, travelling from the 
dorsum of the ilium to the ischiatic notch, and from thence to the fora- 
men ovale ; or directly from the dorsum to the foramen, and back again ; 
or in other directions, according to the character of the original disloca- 
tion ; in some instances these changes being made as often as seven times 
in succession. In the majority of cases no evil consequences seem to 
have followed upon these changes of position. One of my own cases 
will especially serve to show with what impunity sometimes these 
changes may be made. 

" John Caswell, set. 28, was admitted to the Buffalo Hospital of the 
Sisters of Charity on the 13th of January, 1858, with a dislocation of 
the left femur upon the dorsum ilii, which had occurred six days before. 
His own account of the accident was that he was standing at the bottom 
of a well, bent forwards until his body was at a right angle with his 
thighs, when a bucket holding five hundred pounds of earth fell upon his 
back and hips. No attempt had been made to reduce the dislocation. 
Five times in succession manipulation made by myself failed, leaving the 
head of the bone each time upon the dorsum ilii ; the sixth attempt, 
made with the addition of moderate extension by the hands, threw the 
head into the foramen thyroideum. By reversing the movements, it was 
easily replaced upon the dorsum ilii. The seventh trial was made in 
the same manner, except that when I supposed the head of the bone to 
be opposite the lower margin of the socket I did not permit the limb to 
turn either outwards or inwards, but while lifting at the knee with my 
hands, with sufficient power to raise his hips from the table, I brought 
the limb down gradually to a line parallel with the opposite, and thus 
finally the reduction was accomplished. No pain or inflammation fol- 
lowed, and in two weeks he left the hospital ; but whether he was able 
to walk or not at that time, I am unable to say." 2 

Since this paper was written, the following cases have come to my. 
knowledge. December 9, 1865, Dr. James R. Wood attempted, at the 
Bellevue Hospital, the reduction of a dislocation of the femur upon the 
dorsum ilii, of five months' standing, in a man sixty years of age, in the 
presence of Dr. Sayre, myself, and the class of medical students. The 
patient was under the influence of ether. Manipulation alone was em- 
ployed. Probably half an hour had been consumed in the various 
efforts, when, at a moment when the thigh was being forcibly abducted, 
the neck was broken within the capsule, and very close to the head. I 
was able to feel the head of the bone distinctly, after the fracture, and 
to move it freely separated from the neck. 

1 Reduction of Dislocation of the Femur by Manipulation. By the Author. Buffalo 
Medical Journal, Nov. 1857; Feb., March, June, 1859. With tables constructed by 
my very intelligent pupil, Luoien Damainville. 

2 Buffalo Medical Journal, vol. xiii. p. 682. 



UPWARDS AND BACKWARDS ON THE DORSUM TLII. 759 

Dr. David Prince, of Illinois, who was present at the time, informed 
me that he had himself fractured the neck of the femur in attempting 
the reduction of an ancient dislocation of the hip by manipulation. 

In Markoe's paper, published in the New York Journal for January, 
1855, several cases similar to that of Caswell are reported, in which the 
results have been equally fortunate ; but the case mentioned as having 
been under the care of Dr. Post, had a more serious termination. This 
patient, John Kelly, set. 21, had a dislocation into the ischiatic notch, 
and on the same day the reduction was attempted by manipulation. On 
the first trial the head of the bone was thrown into the foramen ovale ; 
and, after having been moved backwards and forwards between these 
two points several times, it was finally carried directly from the foramen 
ovale into the socket by manual extension applied in the ordinary way, 
but without pulleys. "In this case," says Markoe, "the cure was very 
slow, and he left the hospital with some degree of pain and swelling 
about the joint. I learned that an abscess formed in or about the joint, 
which was opened, and when I saw him, a year after, there was every 
appearance of seated morbus coxarius." 

In Case 14, of Markoe's paper, the thigh was broken at the neck after 
manipulation had been employed, but while extension was being made 
by the hands, united with " a lifting outwards." Whether the fracture 
was due to the extension, or to the manipulation, seems not to be clearly 
determined. The dislocation had existed seven weeks when this attempt 
at reduction was made. 

Dr. Bigelow has reported a case of dislocation upon the dorsum, of 
six months' standing, in a man 23 years of age, which he attempted to 
reduce, and caused a fracture of the neck of the femur. His account of 
the manner in which the accident occurred is as follows : " I flexed the 
limb once slowly upward upon the abdomen — a movement which w T as 
attended with a continued fine crepitation about the hip." Upon exami- 
nation, the head of the bone was found to be separated from the neck. 

Dr. Dawson has reported to the Cincinnati Academy of Medicine a 
case in which this accident occurred in his hands. Captain William- 
son, a gentleman in middle life and fair health, was received at Dr. 
Dawson's clinic with a dislocation into the ischiatic notch of nine weeks' 
standing. He was placed under the influence of ether, and various 
methods of manipulation employed. At last " more force was used, the 
thigh was pressed forcibly across the abdomen," and this was followed 
by rapid circumduction. At the sixth repetition of this manoeuvre, the 
neck of the bone suddenly gave way. 1 

Dr. J. S. Wight, of Brooklyn, broke the femur in an attempt to re- 
duce a dislocation of four months' standing. The patient was fifty-three 
years old, and the head of the femur was thought to be in the ischiatic 
notch. Under ether the thigh was flexed upon the body, and then ad- 
ducted with moderate force, when it broke with a loud snap just below 
the trochanter. The fragments subsequently united. 2 

A lad, set. 15, fell through a hatchway, dislocating the left femur 

1 Dawson, The Clinic, Oct. 17, 1874. 

2 Wight, Hosp. Gazette, Sept. 13, 1879. 



760 DISLOCATIONS OF THE THIGH. 

upon the dorsum ilii. The surgeon first called did not recognize the 
accident. April 29, 1873, eight weeks and one day after, this patient 
was received into St. Francis Hospital, and reduction attempted by Drs. 
Hose and Lellman, both gentlemen of experience. It was reduced (ap- 
parently) with ease, the patient being under the influence of ether. 
Extension, with a six-pound weight, was applied to the limb, in order to 
secure quiet, and three days later they found the bone out of place, and 
they repeated the attempt at reduction by manipulation. It was now 
ascertained that the neck of the femur was broken, but whether this 
accident happened in the first or second attempt is not quite certain. 
Two days later I saw the patient, and found the limb shortened one inch 
and a half, and rotated outwards when unsupported. The head of the 
bone could be felt on the dorsum. 

Dr. Rose informs me that Dr. Krackowizer told him that he had just 
met with the same accident. 

Assisted by my pupil, Mr. Hodge, I have also succeeded in collecting 
sixty-two cases of attempts at reduction by extension; a great majority of 
which, we find, were reduced in the first trials; but five cases of recent 
dislocation were not reduced until after several attempts had been made. 

In five cases the femur was broken. The first occurred in St. Tho- 
mas's Hospital, London. Ben. Whittenburg, set. 40, was admitted Nov. 
4, 1827, with a dislocation into the ischiatic notch, of twenty-two weeks' 
duration. After bleeding, etc., had been practised, an attempt was 
made to reduce the bone by pulleys, in which the reporter professes to 
believe they were successful, but on the following day it was plainly 
enough not in place. Mr. Travers again resorted to extension, and while 
extension was kept up and the assistants were rotating the limb out- 
wards, the neck of the femur gave way. 1 Malgaigne mentions a case 
in which, while he was himself directing the operation, the thigh was 
broken through its lower third. He was attempting to reduce the bone 
by extension, but it was not until he gave the signal for rotation out- 
wards that the bone gave way. 2 Gibson says that Dr. Physick, at the 
Pennsylvania Hospital, while engaged in reducing a dislocated thigh by 
the pulleys, broke the femur in consequence of exerting too much force 
upon it in a lateral direction by an additional pulley ; and that a similar 
accident is supposed to have happened to Drs. Harris and Randolph in 
the same hospital, in the year 1838, while using the pulleys upon a boy 
twelve years of age ; for during extension and counter-extension, at the 
moment of rotating the limb, and of drawing it forcibly outwards by a 
towel, a sudden crack was heard. 3 

The fifth case is related by Sir Astley Cooper as having occurred at 
the Brighton Hospital, under the care of Mr. Gwynne ; the dislocation 
was upon the dorsum ilii, and was supposed to have existed about one 
month. The neck of the femur was broken in the first attempt at re- 
duction, and while the surgeon was making extension, with gentle rota- 
tion. 4 



' London Med.-Chir. Rev., Nov. 1828, p. 239. 

2 Malgaigne, op. cit., vol. ii. pp. 146 and 830. 

3 Gibson's Surgery, sixth ed., vol. i. p. 389. 

4 Sir Astley Cooper on Disloc, Amer. ed., p. 88. 



UPWARDS AND BACKWARDS ON THE DORSUM ILII. 761 

Sir Astley says : " There are plenty of cases upon record, of fatal 
abscesses from violent attempts at the reduction of dislocated hips." We 
presume that this remark has reference to attempts at reduction by ex- 
tension, since, in his day, this was almost the only mode in use among 
surgeons. He adds, moreover, that Mr. Skey has mentioned, in the 
Lancet^ a fatal case of phlebitis following protracted extension of the 
thigh. 

Malgaigne has collected no less than eight similar examples, with 
several more in which serious consequences and even death followed 
promptly upon violent attempts at reduction by mechanical means. 2 

The head of the bone has been repeatedly thrown from the dorsum 
ilii into the ischiatic notch ; and B. Cooper mentions a case in which the 
bone was carried from the foramen ovale into the ischiatic notch, from 
which latter position it could not afterwards be changed. 3 

As to the relative chances of failure by the two methods, the testi- 
mony of the recorded cases is equally unsatisfactory. Of the failures 
by extension, the experience of almost every surgeon, the journals, and 
the treatises furnish a sufficient number of examples ; while among the 
sixty-four cases of attempts at reduction by manipulation collected by 
me, and, excepting the cases in which the bone was broken, only two 
were positive failures. It is somewhat remarkable, however, that these 
two cases occurred in the experience of the New York City Hospital ; 
and that they are taken from a total of fifteen, this being the whole 
number which had been treated by this method at the date of these ob- 
servations, in the New York Hospital. One had existed one month, and, 
after repeated trials by manipulation and frequent changes of position, 
it was finally reduced by pulleys. The other, a dislocation into the 
ischiatic notch, had existed only a few hours. At least seven or eight 
trials were made to accomplish the reduction by manipulation, but with- 
out success. The first attempt by extension failed also, but in the second 
attempt the femur was kept at a right angle with the body, and the bone 
was soon brought into its socket. 4 

We have in these two examples not only a record of failure by man- 
ipulation, but an equal record of success by extension ; while, on the 
other hand, we find, in an analysis of the sixty -four cases, sixteen triumphs 
of manipulation over extension. 

We must not omit to mention, in order that the reader may form a 
just estimate of the value of these statistics, that the great majority, es- 
pecially of the cases treated by manipulation, have occurred in private 
practice, and it is unnecessary to say that such statistics do not furnish 
the most reliable basis for conclusions. As a general rule, unsuccessful 
cases are not published by private practitioners, but successful cases are 
pretty certain to be made known ; while, on the other hand, a series of 
cases furnished by any single hospital will generally be found to have 
given both unsuccessful and successful cases. The writer has heard 

1 Op. cit., vol. i. p. 767, 1840-41. Cooper on Disloc, p. 69. 

2 Malgaigne, op. cit., vol. ii. p. 164 et seq. 

3 Sir Astley Cooper on Disloc. Bv Bransby Cooper. Amer. ed., p. 96. 

4 Van Buren, New York Med. Times, Jan. 1856, p.' 126. 
49 



762 DISLOCATIONS OF THE THIGH. 

lately of a complete failure to reduce by manipulation in a recent luxa- 
tion of the hip, after repeated efforts on severul successive days, and 
where skilful surgeons were in attendance ; but it is believed that no 
account of the result has been published. 

We have already called attention to the fact that, in the New York 
City Hospital, two of the fifteen cases reported were failures ; a circum- 
stance of remarkable significance, especially when we consider the skill 
of the several gentlemen who were the operators in these cases ; and it 
plainly renders a new series of statistics necessary, drawn solely from 
the experience of one or more similar large establishments, before we 
shall be prepared to decide positively upon the relative value of the two 
procedures. 

Nevertheless, we shall not hesitate to express our present convictions 
upon this subject, reserving to ourselves the right of a change of opinion 
whenever the proofs shall warrant it. 

Manipulation, owing to the greater power which may be brought to 
bear upon the neck and head of the bone through the action of the shaft 
of the femur as a lever, is most liable to throw the head of the bone 
into new positions, and consequently most liable to rupture the various 
soft tissues about the joint ; to produce inflammation, suppuration, and 
caries. For the same reason it is most liable, also, to fracture the neck 
of the femur. It is not certain in our mind but that, when the princi- 
ples which control the reduction are more completely understood, these 
evils may be lessened ; yet we can scarcely persuade ourselves that by 
any future observations the state of the question will ever be greatly 
changed. We cannot but think, also, that some conclusions ought to be 
drawn from the circumstance that, since the time of Hippocrates to the 
present day, manipulation has been occasionally recommended and suc- 
cessful examples reported ; the reduction being accomplished in most in- 
stances by processes identical, or nearly so, with those now adopted; yet 
generally the writers appear to have been ignorant of what had been 
done before, and, indeed, they have generally avowed their, belief that 
the method suggested by themselves was altogether new and original. 
Possibly this slowness to establish, and total inability to sustain and per- 
petuate a reputation, was not the fault of the method, and had no rela- 
tion to its failures. Until within a few years the number of surgical 
books, and especially of medical journals, was comparatively very small, 
so that valuable truths often died with their discoverers, or were known 
and remembered only by a few ; but it is possible, also, that it has a 
deeper significance, and that it implies some defect in the procedure, or 
serious danger, in consequence of which it has from time to time lapsed 
into disuetude and finally into complete oblivion. 

The Author's Method of Manipulation. — The rules which the author 
would give for the employment of manipulation are very simple. 

The patient being laid on his back upon a mattress, the surgeon, as- 
suming that it is a dislocation upon the dorsum ilii, should seize the foot 
with one hand and the other he should place under the knee ; then, flex- 
ing the leg upon the thigh, the knee is to be carefully lifted toward the 
face of the patient until it meets with some resistance ; it must then be 
moved outwards and slightly rotated in the same direction until resist- 



UPWARDS AND BACKWARDS OK THE DORSUM ILII. 763 

ance is again encountered, when it must be gradually brought downwards 
again to the bed. We do not know that the whole process could be 
expressed in simpler or more intelligible terms, than to say, that the 
limb should follow constantly its own inclination. 

All writers have united in the necessity of flexion ; and, indeed, with 
very few exceptions, the advocates of extension have insisted upon carry- 
ing the dislocated limb more or less across the sound one ; or of making 
the extension at right angles with the body. They have also been 
nearly unanimous in their statements that the thigh should then be ab- 
ducted and finally brought down. Nathan Smith has added the injunc- 
tion to rotate the shaft of the femur outwards, and to press gently upon 
the inside of the knee while the thigh is being flexed upon the body, so 
as to compel the head of the bone to hug the outer margin of the ace- 
tabulum and to prevent its falling into the ischiatic notch ; a suggestion 
which has been erroneously interpreted by some writers to mean that he 
would carry up the limb abducted, a thing which is simply impossible 
until the reduction is accomplished. In adopting this practice, however, 
we must not forget the danger which we incur, when the limb is com- 
pletely flexed, and the head of the femur is below the edge of the ace- 
tablum, of throwing it over into the foramen ovale. Dr. Nathan Smith 
has also noticed the advantage which sometimes may be gained by giving 
to the limb at this moment a slight rocking motion. 

These movements of the limb, with perhaps other slight modifications, 
such as lifting the knee moderately or forcibly when the bone refuses to 
mount over the margin of the acetabulum, pressing with the hand or foot 
upon the pelvic bones, and violent circumduction, are all which have 
been usually practised in successful manipulation. 

We repeat, however, that as a general rule, in the first trial, the knee 
must be carried only in those directions which offer no resistance, and 
these will be found almost always to be the same ; the knee of the dis- 
located femur hanging over the sound one will be made easily to ascend 
to about a right angle with the body ; we can then carry it outwards a 
short distance, probably not more than four or five degrees ; at this 
moment, frequently, the thigh will begin to rotate outwards of itself, and 
with considerable force, or, as Wathman says, " a self-twisting of the 
thigh occurs, which cannot be prevented by fast holding." When this 
action takes place, the reduction is immediately accomplished ; and it is 
in fact at this moment, before the limb begins to descend, that the bone 
most frequently resumes its socket. If it does not, then as soon as the 
limb begins to fall the reduction occurs, generally with a loud snap. It 
is pretty certain that this manipulation is to fail if the knee has de- 
scended more than a few inches without the reduction having taken place ; 
and it will be better to repeat the manoeuvre at once, rather than to 
bring the limb completely down. 

Generally anaesthetics ought not to be employed, since the operation, 
if successful, is not usually painful, and we need that the patient should 
preserve his consciousness, in order to admonish us when we are using 
improper violence. It is probable, also, that the action of certain muscles 
sometimes affords material assistance in the reduction. If, however, the 
patient is very sensitive, or the parts about the joint are very tender, or 



764 DISLOCATIONS OF THE THIGH. 

manipulation without anaesthetics has failed, then certainly these agents 
may be properly and advantageously employed. 

If we propose to attempt reduction by extension, it is no longer neces- 
sary to resort to the lancet, antimony, and the hot bath, as preliminary 
measures, since the muscles can be at once overcome by the much more 
certain and more powerful agents, chloroform, ether, etc. 

Sir Astley Cooper' s Method of Extension. — The method recom- 
mended by Sir Astley Cooper, and most often practised by surgeons of 
the present day, is essentially as follows : — 

The patient is placed upon a bed of suitable height, reclining on his 
back, but partly over upon the sound side. Observing now the line of 
the axis of the dislocated thigh, one strong staple is to be secured into 
the wall upon one side of the room, and another upon the opposite side, 
both of which shall correspond as nearly as possible with the line of the 
shaft of the femur. The staple in front of the body will be higher than 
the bed, and the staple behind will be, in the same proportion, lower 
than the bed. The limb being stripped, two pieces of strong factory 
cloth, each about four inches wide and two feet long, should be laid 
parallel with and on each side of the limb ; the centre of each strip 
being about opposite that portion of the thigh which is just above the 
two condyles. Over the centre of these strips, above the condyles and 
patella, a strong roller, three inches wide and at least three yards long, 
previously wetted in water, is to be turned as tightly as it can be drawn 
until the whole roller is exhausted; the extremity of the roller being 
made fast with a needle and thread rather than with pins. The upper 
ends of the side strips are then to be brought down, and tied to the 
lower ends, forming thus two lateral loops, upon which one of the hooks 
of the compound pulleys is to be made fast, while the other hook is 
secured to the front staple in the wall. Instead of these rollers we may 
employ, if we choose, a leathern thigh-belt. For the purpose of counter- 
extension a sheet is folded diagonally, and its centre being applied to 
the perineum of the dislocated limb, the ends are tied firmly into the 
back staple. To prevent the body from moving laterally, under the 
action of the pulleys, one assistant should be seated upon the bed, with 
his back against the side and back of the patient, and his right arm 
thrown over the body ; it is well also to station another beside the sound 
limb, so as to retain it also in its place upon the bed. Underneath the 
upper part of the dislocated limb a strong and broad bandage should be 
placed, of sufficient length to tie over the neck of the surgeon when he 
is standing about half bent over the body of the patient. 

Everything being arranged, and all portions of the apparatus having 
been sufficiently tested to make sure that nothing will give way during 
the operation, the anaesthetic is to be administered, and as the patient 
falls gradually under its influence, the action of the pulleys should com- 
mence, and be slowly but steadily increased ; a third assistant managing 
the rope, so as to leave the surgeon unembarrassed, and able to direct 
bis whole attention to the position of the trochanter major and of the 
head of the femur. In order to this, he should place one hand upon 
each of these prominences, and watch carefully their descent. 

The length of time which will be required to bring down the limb 



UPWARDS AND BACKWARDS ON THE DORSUM ILII. 765 

must differ greatly in different persons, according to the peculiar cir- 
cumstances of the case, and the condition, age, etc., of the patient ; but 
it must never be forgotten that a slow and steady action is much more 
effective than rapid and irregular tractions, and it is in this especially, 
rather than in the relative amount of power, that the pulleys possess 
always so great an advantage over the hands. 

When the surgeon finds that the head of the bone has nearly or quite 
reached the socket, if it does not take its place spontaneously, he may 
place his neck in the noose which passes underneath the thigh, and lift 
upwards and outwards, in order to raise the trochanter major, and thus 
enable the head to rotate toward the acetabulum. It is in this part of 
the manoeuvre, and especially when at the same moment one of the 
assistants, after bending the leg upon the thigh so as to make of it a 
lever, has rotated the thigh outwards, that the fracture of the neck has 
generally taken place ; and we cannot be too cautious, therefore, parti- 
cularly in old persons, not to bear very strongly upon the noose, nor to 
permit the assistant to rotate outwards with great force. 

If the bone does not enter the socket, we may increase the flexion, or 
suddenly release the tension, or, in fine, again resort to manipulation 
alone. 

When the reduction is accomplished, the patient should be laid upon 
his back, with the knees resting over a pillow, and tied together lightly 
with a towel or a strip of cotton cloth. In order also the more certainly 
to prevent a reluxation, the thigh of the dislocated limb should be gently 
rotated outwards, by which the head will be pressed forwards against 
the anterior portion of the capsule. 

Such an accident, however, as a recurrence of the dislocation, in the 
case of the femur, is exceedingly rare ; and I should have deemed it 
altogether impossible, except as the result of considerable violence again 
applied, had not at least two examples been reported to us upon very 
excellent authority. Malgaigne says he has himself seen an example of 
reluxation upon the dorsum ilii, occasioned by an untimely movement ; x 
and Yerneuil has seen, ten days after the reduction of a dislocation 
upon the ischiatic notch, the dislocation reproduced by a sudden effort 
of the patient to sit up ; 2 indeed, it is when the limb is in a flexed posi- 
tion that the accident seems most likely to occur. 

Of course, in these remarks we mean to except those cases in which 
the upper margin of the acetabulum is broken off, and the head of the 
femur has consequently lost its natural support in this direction. 

The possibility of this accident is also confirmed by the examples of 
" voluntary" dislocations, which I shall relate in the last section of this 
chapter. 

Bigelow' s Method of Extension. — The method of extension recom- 
mended by Dr. Bigelow, namely, with the thigh at a right angle with 
the body, has already been referred to ; and there is much reason to 
believe that, as a rule, it is preferable to extension as practised by Sir 
Astley Cooper. Nearly all surgeons, however, have recognized the ne- 
cessity of flexing the thigh in certain cases. Dr. Bigelow suggests that 

1 Malgaigne, op. cit., torn. ii. p. 830. 2 Ibid., p. 840. 



766 DISLOCATIONS OF THE THIGH. 

where greater force is required than can be obtained by the usual methods, 
a tripod should be employed, as shown in the accompanying wood-cut. 

Fig. 315. 




Tripod for vertical extension. (Bigelow.) 

The following case, reported to me by Dr. N. Fanning, of Catskill, 
N. Y., illustrates the occasional necessity of resorting to extension, and 
is of special interest on account of the extreme youth of the patient. I 
have referred to the same case once before. 

A little girl, two and a half years old, was caught under a falling door 
on the 24th of May, 1867, but her parents suspected no injury beyond 
a severe bruise until ten days later, when they consulted Dr. Fanning. 
The left femur was then found to be dislocated upon the dorsum ilii. Dr. 
Fanning attempted first to reduce the dislocation by manipulation, but 
he failed. He then directed the father to make extension by the legs, 
while the mother made counter-extension by seizing the child under the 
arms, and thus he soon succeeded in effecting the reduction. 



§ 2. Dislocations Upwards and Backwards into the Great Ischiatic Notch. 



Syn. — " Upwards and backwards into the ischiatic notch ;" Sir A. Cooper. " Up- 
wards and backwards into the great sacro-sciatic notch ;" Lizars. " Backwards into 
the sacro-sciatic foramen ;" S. Cooper. " Backwards into the ischiatic notch ;" Liston, 
B. Cooper, Miller, Pirrie, Erichsen, Skey, Gibson. "Downwards and outwards on 
the os ischium;" Boyer, Dorsey, "Backwards and downwards into the ischiatic 
notch;" Chelius, Petit, Duverney. "Upon the ischium;" Bertrandi. "Sacro- 
sciatic;" Cerdy. "Ischiatic;" Malgaigne. " Dorsal below the tendon ;" Bigelow. 

Boyer considers this dislocation as only secondary upon a dislocation 
upon the dorsum ilii ; but it is very certain that it often occurs as a 



UPWARDS AND BACKWARDS INTO ISCHIATIC NOTCH 



767 



primary accident. Not unfrequently, also, what was primarily a dislo- 
cation into the ischiatic notch, becomes subsequently a dislocation upon 
the dorsum ilii. 

Causes. — A fall upon the foot or knee when the limb is very much in 
advance of the body ; or the fall of a heavy weight upon the back and 
pelvis when the thigh is nearly or quite at a right angle with the body. 
Indeed, the causes are very similar to those which produce dislocations 
upon the dorsum ilii, except that it is necessary to suppose the limb in a 
position more nearly at a right angle with the trunk, at the moment in 
which the force is applied. 

Pathological Anatomy. — Mr. Syme, who dissected the body of a man 
recently dead whose thigh had been dislocated into the ischiatic notch, 
found the gluteus maximus nearly torn asunder, the head of the femur 



Fig. 316. 



Fig. 317. 




Dislocation upwards and backwards into 
the great ischiatic notch. (A. Cooper.) 

being imbedded in its sub- 
stance ; the gluteus minimus, 
the pyriformis, and the gemel- 
lus superior lacerated; the 
capsular ligament extensively 
torn close to the edge of the 
acetabulum, and the round lig- 
ament completely separated 
from the femur. The head of 
the femur was lying in the 
great ischiatic notch, upon the 




Dislocation upwards and backwards, into the great 
ischiatic notch. 



768 



DISLOCATIONS OF THE THIGH 



gemelli and the sacro-sciatic nerve, behind the acetabulum and a little 
above it ; being situated between the upper margin of the notch and the 
great sacro-sciatic ligaments. 1 Figure 316 is a representation of this 
specimen. 

Dr. Joseph C: Hutchison, of Brooklyn, N. Y., has reported an exam- 
ple of this dislocation in which, death having occurred four days after 
reduction, he was able to ascertain the character of the lesions. By the 
courtesy of Dr. Hutchison, I was permitted to be present at this autopsy, 
and the lesions were found to be much the same as in the case related by 
Syme ; but the gluteus minimus was not torn, and there was added a 
laceration of the obturator externus. Dr. Lente has reported one other 
dissection made after reduction. 2 

Fig. 318. 




Internal obturator in its natural position. (Bigelow.) 

Dr. Bigelow speaks of a dorsal (upon the ilium) dislocation as some- 
times occupying a position as low as the upper portion of the ischiatic 
notch ; but the dislocation now under consideration he describes as that 
in which the head of the femur, having been driven from its socket 
downwards and backwards, is subsequently, in the attempt to straighten 
the limb, carried upwards behind the socket until it is arrested by the strong 
tendon of the obturator internus, and the subjacent capsule. This is 
usually denominated " ischiatic ;" but as it is both behind and below the 
tendon, Bigelow calls it " dorsal below the tendon." 



1 Amer. Journ. Med. Sci., vol. xxxii. p. 460. 

2 Lente, New York Journ. Med., Jan. 1851. 



UPWARDS AND BACKWARDS INTO ISCHIATIC NOTCH 



769 



Symptoms. — The position of the limb is in some cases nearly the same 
as in certain dislocations upon the dorsum. It is shortened usually about 



Fig. 319. 




Internal obturator in its new position. (Ischiatic) " Dorsal below the tendon." (Bigelow.) 



Fig. 320. 



half an inch, the thigh being flexed upon the body, adducted, and ro- 
tated inwards ; but the flexion is often less than in dislocations upon the 
dorsum, while, on the other hand, it 
is sometimes much greater. Gene- 
rally it is such that, when the patient 
is standing, the end of the great toe 
of the dislocated limb touches the 
ball of the great toe of the sound 
limb. 

Bigelow observes that the extreme 
flexion which is sometimes found to 
exist, especially when the patient is 
in the recumbent position, is gene- 
rally due to the arrest of the head of 
the femur by the internal obturator 
and the subjacent untorn capsule. 
When the patient rises, the weight of 
the limb may force the head up be- 
hind the tendon of the obturator ; or 

if the limb is brought down With force, dislocation upwards and backwards into 

, , -II • erreat iscliiatic notch. " Below the tendon," 

the tendon and capsule may give way when the patient is recumtent . (Bigeiow.) 




770 DISLOCATIONS OF THE THIGH. 

and the head may ascend to any point upon the outer surface of the 
ilium, and in this way an ischiatic may be converted into an iliac dislo- 
cation. 

The head of the femur is sometimes distinctly felt in its new position, 
especially when the limb is moved upwards or downwards. The tro- 
chanter major is approximated toward the anterior superior spinous pro- 
cess of the ilium. 

Sir Astley Cooper remarks that this dislocation is the most difficult to 
detect, and Mr. Syme mentions a case in which the nature of the acci- 
dent was overlooked by himself, and the thigh was not reduced until the 
thirteenth day j 1 and subsequently Mr. Syme has called attention to 
w T hat he considers as one of the most important diagnostic marks — indeed, 
he says it is never absent, nor is it ever met with in any other injury of 
the hip-joint, " whether dislocation, fracture, or bruise ;" this is " an 
arched form of the lumbar part of the spine, which cannot be straight- 
ened so long as the thigh is straight, or on a line with the patient's 
trunk. When the limb is raised or bent upwards upon the pelvis, the 
back rests flat upon the bed ; but so soon as the limb is allowed to de- 
scend, the back becomes arched as before." 2 This position, assumed by 
the back when an attempt is made to straighten and depress the limb, is 
due to the action of the psoas magaus and iliacus internus. But this 
can hardly be regarded as absolutely diagnostic, inasmuch as this same 
phenomenon will be observed in a degree, more or less, in a dislocation 
upon the dorsum, and in most cases of disease of the hip-joint. The in- 
version of the toes, immobility of the limb, and the absence of crepitus, 
are generally sufficient in themselves to distinguish it from a fracture of 
the neck. Dr. Squires, of Elmira, N. Y., in a note addressed to me in 
March, 1860, suggests, also, that in ancient cases the projection of the 
head of the femur may be felt by passing the finger into the rectum or 
vagina. With my finger in the rectum I determined a dislocation into 
the ischiatic notch which had existed six months, in a boy twelve years 
old ; and by exploration per vaginam I diagnosticated the same disloca- 
tion in a woman at Bellevue Hospital, which had existed four weeks. 

Dr. Oscar H. Allis, of Philadelphia, has added another valuable 
means of diagnosis, namely, that, although the limb, when laid parallel 
w T ith the other, or as nearly so as it is practicable to place it, and ex- 
tended, will be found to be only very little shortened, if at all ; yet, 
w T hen the two limbs are brought into a position of flexion, the thighs 
being at right angles with the body, the dislocated limb will appear one 
or two inches shorter than the other — that is, the knee of the dislocated 
limb will be on a much lower level than the other. 3 

Dr. W. Dawson, of Cincinnati, w T hose observations in relation to this 
new sign extended back as far as 1871, and who had repeated the ob- 
servation several times, published his experience in 1878, without being 



1 Am. Journ. Med. Sci. vol. xviii. p. 242. 

2 Am. Journ. Med. Sci., Oct. 1843, p. 461, from Lond. and Edinb. Month. Journ., 
July, 1843. 

3 Allis, Philad. Med. Times, March 28, 1874. 



UPWARDS AND BACKWARDS INTO ISCHIATIC NOTCH. (71 

aware that Dr. Allis had already called the attention of the profession 
to this point. 1 

Prognosis. — I have seen two dislocations of this character which 
were not recognized by the surgeons at the time of the receipt of the 
injury, nor for some weeks afterwards. One was in a lad twelve years 
old, who was brought to me from an adjacent county in August, 1847. 
The accident had happened eight weeks before. His limb was shortened 
one inch; it was also forcibly adducted and rotated inwards. Dr. Cole- 
grove, a very excellent surgeon, had made a thorough attempt to reduce 
the dislocation with pulleys a few days before he was brought to me, 
and I did not deem it advisable to subject him again to the trial. Not- 
withstanding the dislocation, his limb was quite useful. The second 
was in the case of the boy seen by Dr. Sayre and myself, to which I 
have just referred. 

Treatment. — In employing mmiipulation, we may follow, with only 
a slight modification, the directions already given in dislocations upon 
the dorsum ilii. We find the head of the femur lower; consequently the 
extent of the circuit to be described in the manoeuvre is diminished, but 
in other respects the processes are identical. 

We must not forget, however, that there is especial danger, while 
attempting to reduce this dislocation by manipulation, that the head of 
the bone will be thrown across into the foramen thyroideum. I have 
already mentioned one case occurring under the care of Dr. Post in the 
New York Hospital, in which the head of the femur, originally in the 
ischiatic notch, passed backwards and forwards between the ischiatic notch 
and the foramen thyroideum many times, and which, although the reduc- 
tion was finally accomplished, was followed by morbus coxarius. Parker 
mentions a second case in the same paper, 2 in which his first attempt to 
reduce by manipulation carried the head of the bone into the foramen 
thyroideum ; but the second attempt was successful. In Dr. Hutchison's 
case, to which I have already referred, the first attempt at reduction 
was made without an anaesthetic, and by manipulation after the method 
described by Reid. The first two attempts failed, and in the third, the 
limb being more abducted than before, the head of the bone was thrown 
into the foramen thyroideum. By reversing the movements, it was re- 
placed in the ischiatic notch ; and this change of position was made seven 
or eight times. The patient w T as now etherized, and the bone was lifted 
into its socket in the same manner which I have described in the case of 
Caswell. Malgaigne refers to a patient of Lenoir's, and to another of 
his own, in which the head of the bone was lodged under the margin of 
the acetabulum during the attempts at reduction. 3 

On the 28d of March, 1855, Charles McCormick, set. 21, a laborer on 
the " State Line Railroad," was caught between two cars, with his back 
resting against one car, and his right knee against the other, the right 
thigh being raised to a right angle with his body. As the cars came 
together he felt a "cracking" at his hip-joint, and found himself imme- 
diately unable to walk or stand. 

1 Dawson, Archives of Clinical Surg., Jan. 1, 1878. Hosp. Graz., May 16, 1878. 

2 Markoe's paper, N. Y. Journ. of Med., Jan. 1855. 

3 Malgaigne, op. cit., torn. ii. p. 839. 



772 DISLOCATIONS OF THE THIGH. 

Two hours after the accident, assisted by my son Theodore, and Aus- 
tin Flint, Jr., I examined the limb carefully, and made arrangements for 
the reduction with the pulleys, in case the attempt by manipulation 
should fail. 

The patient lying upon his back, I seized the right leg and thigh with 
my hands, the leg being moderately flexed upon the thigh, and carried 
the knee slowly up toward the belly, until it had approached within 
twelve or fifteen inches, when, noticing a slight resistance to farther pro- 
gress in this direction, I carried the knee across the body outwards, until 
I again encountered a slight resistance, and immediately I began to 
allow the limb to descend. At this moment a sudden slip or snap oc- 
curred near the joint, and I supposed reduction was accomplished ; but 
on bringing the limb down completely, I found it was still in the ischiatic 
notch. I think the head had slipped off from the lower lip of the aceta- 
tabulum, after having been gradually lifted upon it. 

Without delay I commenced to repeat the manipulation, and in pre- 
cisely the same manner. Again, at the same point, when the limb was 
just beginning to descend, a much more distinct sensation of slipping was 
felt, and on dropping the limb it was found to be in place and in form, 
with all its mobility completely restored. 

No anaesthetic was employed, and no person supported the body or 
interfered in any way to assist in the reduction. No outcry was made 
by the patient, yet he informed me that the manipulation hurt him con- 
siderably. The amount of force employed by myself was just sufficient 
to lift the limb, and the time occupied in the whole procedure was only 
a few seconds. 

After the reduction he remained upon his back, in bed, eleven days, 
in pursuance of my instructions. At the end of this time he began to 
walk about, but was unable to resume work until after eight weeks or 
more. It is probable that he could have walked immediately after the 
reduction, without much if any inconvenience, so trivial was the inflam- 
mation which resulted from the accident. He never complained of pain, 
but only of a slight soreness back of the trochanter major, near the head 
of the bone. This soreness continued several weeks, and was especially 
present when he bent forwards. After the lapse of four months, when I 
last saw him, he occasionally felt a pain at this point in stooping, but the 
motions of the joint were free; he walked rapidly and without halt. 

If the reduction is attempted by extension^ we ought to remember 
that the head of the bone lies more behind than above the socket, and 
that it is not requisite to carry it downwards so much as forwards ; and 
especially that it must mount over the most elevated margin of the 
socket, in order to resume its position. The extension ought, therefore, 
to be made at a right angle with the body, as the following case will 
illustrate : — 

John Hebden, set. 40, was sitting with his legs hanging over the dock, 
when his left knee was struck by a ferry-boat, dislocating the head of 
the femur into the ischiatic notch. I found him at Belle vue Hospital on 
the following morning, about twenty hours after the accident, September 
29, 1866. In the recumbent posture the limb was pretty strongly ad- 
ducted and slightly rotated inwards. It was shortened three-quarters of 



UPWARDS AND BACKWARDS INTO ISCHIATIC NOTCH. 773 



an inch. In the erect posture both adduction and inward rotation were 



very slight. 



Having etherized him, I made three separate attempts at reduction 
by manipulation, but failed. I then made extension in the following 
manner : The patient resting upon his back, I stood astride his body, 
and clasping my hands under the knee, I pulled directly upwards, while 
an assistant held down the pelvis. I did not feel the bone resume its 
place, nor was I aware that reduction was accomplished, but when I let 
the limb down the bone was found to be in its socket. 



Fig. 321. 




Reduction of dislocation upwards and backwards into the great ischiatic notch, by extension. 
(Sir Astley Cooper's Method.) 



Two or three minutes later, and before the patient had recovered 
from the effects of the ether, I raised the knee, to indicate to some 
young men, who had just come in, how the dislocation had been reduced, 
when it slipped out again, with a sudden jerk and a grating sensation, 
This sensation I had felt once or twice before while manipulating. It 
was scarcely as rough as the crepitus of a fracture, and it probably in- 
dicated that the cartilaginous margin of the acetabulum had been 
broken off. 

The limb was now brought down to the bed, and it was found to be 
in the same position as before reduction was attempted. Standing 
again over the patient, and placing my hands under the knee, I pulled 
upwards, and the head resumed its place ; this time with a sudden jerk 
and with the same rough sensation. The limb was then placed in the 



774 DISLOCATIONS OF THE THIGH. 

extended position and secured by a long splint, which was not removed 
until the eleventh day. 

The facility with which the reluxation took place in the preceding 
case will sufficiently explain what happened in the following case on the 
tenth day after reduction, and on account of which I was subsequently 
consulted. 

William Milne, set. 19, of Orleans County, N. Y., was thrown from 
a wagon May 13, 1858, dislocating his left femur into the ischiatic 
notch. Dr. Watson, of Clarendon, Orleans County, was consulted 
within three hours. Drs. Wood and Tafft were also present. Dr. 
Watson laid the patient on his back, and without anaesthetics reduced 
the dislocation by manipulation. The bone was felt distinctly as it 
slipped into its place, and the limb immediately resumed its natural 
position and length, as all the surgeons present affirm. He was soon 
out of the house on crutches, and on the eleventh day went in bathing. 
When he came out of the water he complained of his hip, and on the 
following day it was seen to be shortened. Subsequently it was ex- 
amined by several surgeons, all of whom pronounced it dislocated. An 
attempt was then made to reduce the dislocation by Jarvis's adjuster, 
but without anaesthesia, as the patient refused to be rendered insensible. 
The attempt did not succeed, and the father brought an action against 
Dr. Watson in the Supreme Court of Orleans County, Judge Noah Davis 
presiding, for September, 1858. The prosecutor failed to appear, and 
Dr. Watson, the defendant, took judgment by default. 
- Lente relates a case in which, extension being employed, the cord was 
suddenly cut while the limb was abducted and rotated outwards, when 
the head of the femur left the ischiatic notch, and rose upon the dorsum 
ilii, assuming a position directly above the acetabulum, and below the 
anterior superior spinous process ; and from which position it was subse- 
quently, with great difficulty, returned to the socket. 1 

§ 3. Dislocations Downwards and Forwards into the Foramen Thyroideum. 

Syn. — "Downwards into the foramen ovale ;" Sir A. Cooper. "Downwards into 
the obturator foramen ;" Lizars. " Downwards and forwards into the foramen obtu- 
ratorium;" B. Cooper. "Inwards and downwards into the oval hole;" Chelius. 
"Downwards and forwards into the foramen ovale;" Pirrie. "Downwards aiid 
inwards)" Boyer. "Subpubic;" Gerdy. " Ischio-pubic ;" Malgaigne. 

Causes. — In order to produce this dislocation the limb must be, at 
the moment of the receipt of the injury, in a position of abduction. 
Perhaps most often it is occasioned by the fall of a heavy weight upon 
the back of the pelvis when the body is bent and the thighs spread 
asunder. 

Pathological Anatomy. — The capsule gives way upon the inner side 
especially ; the round ligament is torn from its attachment, and the 
head of the femur, pressing forwards and downwards, finds a lodgment 
upon the obturator externus muscle, over the foramen thyroideum. 

Symptoms. — The thigh is lengthened from one to two inches, ab- 
ducted and flexed, the body being also bent forwards or flexed upon the 

1 Lente, New York Journ. Med., November, 1850, p. 314. 



INTO THE FORAMEN THYROIDEUM. 



775 



thigh. The dislocated limb is advanced before the other, and the toes 
generally point directly forwards, but they may incline either outwards 
or inwards. The hip is flattened or depressed ; the long adductors are 
felt tense upon the inside of the limb ; the trochanter major is less 
prominent than upon the opposite side ; and the head of the bone may 
sometimes be felt in its new position. The lengthening of the limb alone 
is sufficient to distinguish this accident from a fracture of the neck. 

The flexion and abduction are due in some measure to the tension of 
the psoas magnus and iliacus internus, and perhaps to a similar condition 
of other rotators and flexors ; but, according to Bigelow, the ilio-femoral 



Fig. 322. 



Fig. 323. 





Relations of the ilio-femoral ligament to the thyroid 
dislocation. (From Bigelow.) 

ligament offers the chief resistance, 
and constitutes the chief impediment 
to the restoration of the bone. 

Treatment. — It is pretty certain 
that in the following example there 
was a spontaneous reduction, or rather, 
I ought to say, an accidental reduc- 
tion of a dislocated femur from the thyroid foramen. Perhaps it was 
only an example of a partial luxation ; of which species of forward lux- 
ation I shall hereafter relate another case as having come under my 
own notice. 

Jacob Lower, ast. 10, fell from a tree, a height of about twelve feet, 



Dislocation downwards and forwards into the 
foramen thyroideum. 



776 DISLOCATIONS OF THE THIGH. 

to the ground. It is not known how he struck. He became imme- 
diately quite faint, and when he had partly recovered, he attempted to 
get up, but could not. He said his leg was broken, and cried out lustily 
whenever it was moved. The father arrived in about an hour, and found 
him still lying on his back where he had fallen, with his right leg car- 
ried away from the other, and turned outwards. He lifted him up to 
place him in a small hancLwagon, which was long enough for his body, 
but only one foot and a half in width. Finding that his right leg was 
so much abducted as to prevent his being laid in so narrow a space, he 
seized upon it, and with some force pressed the knee inwards across the 
opposite leg, when suddenly it resumed its position with a loud snap like 
a "cannon." I use the language of the father. On the following day 
I examined the limb carefully, and found its motion free. He was, how- 
ever, vomiting the contents of his stomach, and passing blood from the 
bladder quite freely. The vomiting soon ceased, but the hemorrhage 
from the bladder continued three or four days. On the ninth day he 
walked out, and on the twelfth he was seen climbing upon the top of a 
house. I saw him again after the lapse of a year, and found that he 
was still complaining of an occasional soreness in the region of the hip- 
joint. 

If we attempt to reduce by manipulation, it will be proper to follow 
the same rule which we have stated as applicable to dislocations back- 
wards, namely, to carry the limb, in the first instance, only in those 
directions in which it is found to move easily. Instead, therefore, of 
holding the leg in a. position of adduction while the thigh is flexed upon 
the abdomen, it will be necessary to carry it up abducted ; and when 
the further progress of the knee toward the belly is arrested, the limb 
must be moved inwards, and finally brought down adducted. When the 
knee is about opposite the pubes, or a little lower, in its descent, the 
femur should be gently rotated inwards, for the purpose of directing the 
head toward the acetabulum. The reduction may also be sometimes 
facilitated by lifting the head of the bone with the aid of a band passed 
under the upper portion of the thigh and over the shoulder of an assist- 
ant ; by giving to the shaft of the femur a slight rocking motion when it 
is about to enter the socket ; and also by pressing with the hand against 
the head of the bone, or by lifting at the knee moderately, 

In one of the examples recorded by Markoe (Case 8), the reduction 
was accomplished in the second attempt, by rotating the thigh inwards 
just as the thigh had descended below a right angle with the body, in the 
manner which we have above directed ; but in a second example (Case 9), 
a similar manoeuvre carried the head across into the ischiatic notch, while 
the reduction was finally accomplished by rotating the thigh outwards, 
and at the same moment adducting the limb strongly in a direction which 
carried the knee behind the other one. Markoe concludes that the latter 
mode is preferable, because it will throw the head of the bone a little 
upwards as well as outwards ; in which direction it will find a more gently 
inclined plane toward the socket. He admits, however, that both methods 
may accomplish the same result. But I am quite certain that the method 
by rotation of the shaft of the femur inwards is in general most likely 
to succeed. In this way also, I think, both W. H. Van Buren, of New 



INTO THE FORAMEN THYROIDEUM 



777 



York, 1 and R. L. Brodie, of the U. S. Army, were successful; 2 it is the 
method preferred by Bigelow, who also recognizes the propriety of making 
outward rotation when inward rotation fails. " Flex the limb towards a 
perpendicular, and abduct it a little to disengage the head of the bone ; 
then rotate the thigh strongly inward, adducting, and carrying the knee 
to the floor." It is especially worthy of notice that Anderson, so long 

Fig. 324. 




Eeduction of thyroid dislocation by manipulation. (From Bigelow.) 

ago as 1772, in the case already quoted when we were considering the 
history of reduction by manipulation, practised successfully almost pre- 
cisely the same method. In one example mentioned by Markoe (Case 
7), it is pretty evident that the head of the femur was thrown into the 
ischiatic notch, by having flexed the thigh too much, so that " the knee 
touched the thorax." Indeed, it is questionable whether it will be best 
ever to bring the thigh much, if at all, above a right angle with the body, 
since any further flexion can only throw the head below the acetabulum, 
when in fact it is already too low. 

July 21, 1858, Nathaniel Smith, a painter by trade, jet. 33, fell from 
the second-story window of the city post-office, Buffalo, upon a stone 
pavement, striking, as he believes, upon the inside of his right knee. I 
saw him within an hour, and found the right tibia partially dislocated 
outwards, the corresponding patella dislocated completely outwards, and 
the right femur in the foramen thyroideum. His thigh was forcibly ab- 

1 W. H. Van Buren, New York Med. Times, Jan. 1856, p. 127. 

2 R. L. Brodie, Memphis Med. Recorder, Sept. 1857, p. 93 ; from Charleston Med. 
Rev. 

50 



778 



DISLOCATIONS OF THE THIGH 



ducted, slightly rotated outwards, and lengthened, by measurement made 
from the pelvis to the ankle, one inch and a half. The distance from 
the anterior superior spinous process to the fold of the groin was ten 
inches, but upon the sound side it was only eight and a half. The head 
of the femur could be distinctly felt in front, just under the pubes. 

Having administered chloroform, I first reduced the tibia and the 
patella, then seizing the thigh and leg, I flexed the thigh upon the body, 
carrying the limb upwards abducted until it was nearly or quite at a right 
angle with the body, then inclining the knee slightly inwards, I brought 
it down again, and when the thigh had nearly reached the bed, it fell 
into its socket with a dull flapping sensation. In every step of the pro- 
cedure I followed the inclination of the limb. The recovery was rapid 
and complete. 

Sir Astley Cooper says that this dislocation is in general reduced very 
easily by the aid of pulleys ; at least if the accident is recent. He 
advises that the patient shall be placed upon his back, with his thighs 
separated as far as possible. The pulleys are to be made fast to a band 



Fig. 325. 




Sir Astley Cooper's mode of reducing a recent luxation into the foramen thyroideum. 

drawn across the perineum of the dislocated limb, in a direction up- 
wards and outwards ; while a counter-band is to be passed around the 
pelvis through the band attached to the pulleys, and secured to a staple, 
or delivered to assistants placed upon the sound side of the body. When 
everything is arranged, the pulleys should be acted upon until the head 
of the femur is felt moving from the foramen thyroideum ; at this moment 
the surgeon must pass his hand behind the sound limb, and seizing upon 
the ankle of the dislocated limb, adduct it forcibly, thus converting the 
limb into a lever of the first order. 



INTO THE FORAMEN THYROIDEUM 



779 



If the dislocation has existed some time, he recommends that this pro- 
cedure shall be varied by placing the patient upon his sound side instead 
of his back, and attaching the pulleys perpendicularly over the body. 
Sir Astley especially cautions us not to flex the thigh during these 
manoeuvres, lest we force the head of the bone backwards into the ischi- 
atic notch, from whence he affirms that it cannot afterwards be returned 
to its socket ; but the experience of surgeons has since shown that this 
latter statement is incorrect, and that it may, in some cases, be after- 
wards reduced, although it has fallen into the ischiatic notch. Mr. Lis- 
ton says that this accident happened to himself while attempting to 
reduce a dislocation of only a few hours' standing, in a young and pow- 
erful man, but he had no difficulty in returning it to its first position. 1 

Brainard, of Chicago, reduced a dislocation of that form of which we 
are now speaking, after both the compound pulleys and Jarvis's adjuster 
had failed, by placing between the thighs a piece of wood wrapped about 
with several layers of a wadded quilt, and making use of this as a ful- 
crum upon which the thigh operated as a lever. The legs were simply 
pressed together, care being taken to keep the knees straight. 2 

The majority of surgeons of the present day place the limb in the 
flexed position before attempting to make traction. This may be done 
with the patient lying upon his back, and by the hands, alone, or with 
pulleys, or the patient may be placed in a sitting posture, and the extension 
made at right angles with the body. In all of these attempts to reduce 
by traction, measures must be taken to secure immobility to the pelvis. 

May 23, 1868, a man, 40 years of age, was admitted to Bellevue, 
having a dislocation of the left femur into the foramen thyroideum, 
which had been caused six hours 
before by the fall of a heavy 
weight upon his back while 
stooping. The limb was slightly 
abducted, and moderately flexed 
upon the pelvis, while he was 
lying upon the bed ; the position 
being that represented in Fig. 
323. There was a very marked 
depression in the situation of the 
trochanter major, and a fulness 
upon the inside of the limb, 
caused by the tension of the 
long adductors. 

The patient being under the 
influence of ether, the house sur- 
geon, Dr. E. D. Hudson, first 
attempted, under my instruction, 
to reduce the dislocation by ma- 
nipulation, flexion, and rotation, 
with adduction ; but failing in 
this, a folded sheet was placed 



Fig. 326. 




Effect of flexion upon the ilio-femoral ligament in 
the thryoid dislocation. (From Bigelow.) 



1 Practical Surg., Amer. ed., p. 93. 

2 Brainard, Northwestern Med. and Surg. Journ., 1852. 



780 DISLOCATIONS OF THE THIGH. 

in the perineum corresponding to the dislocated limb, and committed to 
assistants, who were directed to pull upwards and outwards, the patient 
lying upon his right side, with his left thigh flexed to a right angle with 
his body. Dr. Hudson then passed a band under the upper part of the 
thigh and over his shoulders, lifting and pressing the knee forcibly 
inwards at the same time. In a few seconds the reduction was accom- 
plished. 

After the reduction is accomplished, the patient should be laid upon 
his back in bed, but instead of rotating the limb outwards, as we have 
advised after a dislocation upon the dorsum ilii or into the ischiatic 
notch, it should be gently rotated inwards, and the knees thus bound 
together. 

§ 4. Dislocations Upwards and Forwards upon the Pubes. 

Syn. — "Upwards and forwards on the horizontal branch of the share-bone;" 
Chelius. " Forwards upon the pubes ;" Pirrie. " On the body of the pubes, below 
the spine and transverse part of the bone ;" Skey. "Sur-pubic;" Gerdy. "Ilio- 
pubic;" Malgaigne. 

Causes. — This accident is generally occasioned by a fall upon the foot 
when the leg is thrown backwards behind the centre of gravity ; as in a 
fall from the back end of a wagon, the foot being instinctively thrown 
backwards in order to save the head ; or it may happen to a person who, 
while walking, suddenly puts one foot into a hole, in consequence of 

Fig. 327. 




Specimen of dislocation upon the pubes, in St. Thomas's Hospital (From Sir A. Cooper.) 

which the pelvis advances, but the leg and upper part of the body incline 
forcibly backwards. Occasionally it has resulted from a fall upon the 
back of the pelvis, or from a severe blow received upon the same part. 
A patient was admitted, under the care of Dr. Ure, into St. Mary's 
Hospital, London, with a dislocation upon the pubes occasioned by swim- 



UPWARDS AND FORWARDS UPON" THE PUBES. 



781 



ming. His account of it was, that when in the act of " striking out" he 
felt a catch in the right groin which he thought was cramp, and that he 
was able to walk after the accident, but with a good deal of difficulty. 
The examination proved that he had a dislocation upon the pubes, which 
Dr. Ure easily reduced. 1 

Pathological Anatomy. — Sir Astley Cooper dissected the hip of a 
person whose thigh had been dislocated upon the pubes for some time, 
the true nature of the accident not having been at first recognized. The 
acetabulum was partly filled by bone, and partly occupied by the tro- 
chanter major, both of which were much altered in their form. The 
capsular ligament was extensively torn, and the ligamentum teres broken 
off completely. The head and neck of the femur had torn up Poupart's 
ligament, so as to penetrate between it and the pubes, and lay under- 
neath the iliacus internus and psoas muscles ; the anterior crural nerve 
was lying upon these muscles, over the neck of the femur. . The head 
and neck were flattened and other- 
wise much changed in form. Upon Fro. 323. 
the pubes a socket was formed for 
the neck of the thigh-bone, the 
head being above the level of the 
pubes. The femoral artery and 
vein were to the inner side. The 
specimen is still preserved in St. 
Thomas's Hospital (Fig. 327). 

The head* of the femur may be 
found lying far forward upon the 
pubes, as in Physick's case men- 
tioned below ; or it may lie farther 
back, along the ilio-pubic margin, 
and rest below and in front of the 
anterior superior spinous process 
of the ilium. When the head 
rests directly below this process, 
the dislocation is considered anom- 
alous or irregular, and this form 
will be considered hereafter as 
the "subspinous" dislocation. 

In the accompanying drawing 
the relation of the ilio-femoral 
ligament to the head and neck of 
the femur is shown, when the 
head ascends moderately upon 
the pubes. The extreme displace- 
ment shown in the preceding il- 
lustration from Sir Astley Cooper 

is only possible where that portion of the capsule beneath the obturator 
internus is torn, and perhaps the obturator itself. According to Bige- 
low, the ilio-femoral ligament and the psoas magnus and iliacus internus 
are then the only remaining causes of eversion. 




Dislocation upon the pubes below the antei-ior infe- 
rior spinous process of the ilium. (From Bigelow.) 



1 Medical News and Library, vol. xvi. p. 1, from Lond. Lancet, Nov. 7, 1857. 



782 



DISLOCATIONS OF THE THIGH. 



Symptoms. — The thigh is shortened sometimes, but not always, ab- 
ducted, flexed slightly, rarely extended, and rotated outwards. The 
trochanter major is carried back and lost, or nearly so, while the head of 
the bone may be generally felt like a round ball, lying upon or in front 
of the body of the pubes outside of the femoral artery and vein. Larrey 
saw a patient in whom the femur was placed nearly at a right angle with the 
body; and Physick once met with a dislocation upon the pubes "directly 

before the acetabulum," in which 
Fl <*- 329. the limb was not at all shortened, 

but on the contrary, a very little 
lengthened. 1 Other surgeons have 
occasionaly seen similar examples. 
The differential dagnosis between 
a fracture of the neck of the femur 
and this dislocation may be thus 
briefly stated. In the fracture 
there is crepitus, mobility, slight 
e version easily overcome, no ab- 
duction, the trochanter major ro- 
tates on a short radius, and the 
head of the bone cannot be felt. 
In this dislocation there is no crepi- 
tus, the limb is immobile, the e ver- 
sion is extreme and not easily over- 
come, the thigh is ofte*n abducted, 
the trochanter major rotates upon 
a longer radius, and the head of 
the bone can generally be distinctly 
felt in its unnatural position. 

Prognosis. — Sir Astley Cooper 
remarks that although this accident 
is easy of detection, he has known 
three instances in which it was 
overlooked, and he cannot but re- 
gard such errors as evidence of 
great carelessness on the part of 
the surgeon who is employed. 

The reduction has generally been 
accomplished, in recent cases, with 
no great difficulty ; and when not 
reduced, the patients have occa- 
sionally recovered with very use- 
ful limbs. 

Treatment. — From the several 
reported examples of dislocation 
upon the pubes reduced by ma- 
nipulation, it would be difficult to draw any practical conclusions, since 
the methods have differed so widely from each other. I shall mention 




Dislocation upwards and forwards upon the 
pubes. 



1 Dorsey's Surgery, vol. i. p. 238, 1813. 



UPWARDS AND FORWARDS UPON THE PUBES. 783 

only four, which may be found in our own journals. One of these has 
already been mentioned in connection with the history of this process, 
as a case of compound dislocation reduced by Dr. Ingalls, of Chelsea, 
Mass. ; and two examples were reported by E. J. Fountain, of Daven- 
port, Iowa. Dr. Ingalls succeeded by carrying the limb into its greatest 
state of abduction, and rotating the thigh inwards ; the replacement of 
the bone being aided also by pressing upon its head with his fingers 
thrust into the wound ; while Dr. Fountain succeeded equally in both of 
his cases, by an almost opposite mode of procedure, namely, by adduct- 
ing the limb forcibly, rotating the thigh outwards, and then flexing the 
thigh upon the body. 

The first of Dr. Fountain's cases occurred in June, 1854. The 
patient, an adult male, had fallen from the second story of a house to 
the ground, fracturing his lower jaw, and dislocating his left hip. The 
limb was a trifle shortened, and the foot strongly everted. The pro- 
minence of the trochanter was lessened, and the head of the bone could 
be felt upon the pubes. Assisted by Dr. Arnold, he reduced the limb 
in the following manner : The patient was laid on the floor, and placed 
completely under the influence of chloroform. The dislocated limb was 
then " seized by the foot and knee and rotated outwards, the leg flexed 
and carried over the opposite knee and thigh, the heel kept well up, 
and the knee pressed down. This motion was continued by carrying 
the thigh over the sound one as high as the upper part of the middle 
third, the foot being kept firmly elevated. Then the limb was carried 
directly upwards by elevating the knee, while the foot was held firm and 
steady, at the same time making gentle oscillations by the knee, when the 
head of the bone suddenly dropped into its socket." 1 The time occupied 
was not more than thirty seconds, and the force employed was very slight. 

The second case occurred on the 31st of October, 1855, in the person 
of John McCarthy, an Irish laborer ; the dislocation having been oc- 
casioned by falling with a horse, while riding. The reduction was 
effected in about twenty seconds by the same process, and without the 
aid of chloroform. 

Dr. Henry, of New York, successfully reduced a dislocation of the 
femur upon the pubes after twent} 7 -six days. The first attempt, made 
October 23d, was unsuccessful. The second attempt was made October 
29th. After repeated trials, by forced abduction and circumduction the 
head of the bone was thrown into the thyroid foramen, after which by 
abduction and extension it was conveyed into the acetabulum. He was 
dismissed cured in about three months. 2 

It is probable that no one method will succeed equally well in all cases ; 
but if the head of the bone, as in the case dissected by Sir Astley Cooper, 
has not only actually surmounted the pubes, but pushed itself fairly into 
the pelvis, then the limb ought to be abducted in the manner practised 
by Ingalls, and forcibly rotated outwards, in order that the head may be 
thus lifted over the pubes ; and subsequently it should be flexed upon 
the body, adducted and brought down. But in this manoeuvre we ought 
to be careful not to continue the rotation outwards after the head of the 

1 Fountain, New York Journ. Med., Jan. 1856, p. 69 et seq. 

2 M. H. Henry, Am. Journ. Med. Sci., Jan. 1875. 



784 DISLOCATIONS OF THE THIGH. 

femur has risen above the pubes, lest the head and neck should grasp, 
as it were, the psoas magnus and iliacus internus muscles, underneath 
which they have been thrust. On the contrary, it will be necessary at 
this point to rotate the thigh again gently inwards, which, by compelling 
the head to hug the front of the pubes, aviII enable it, while the flexion 
is being made, to slide downwards under these muscles toward the 
socket. If, however, the head of the bone has never risen upon the 
summit of the pubes, and is not actually engaged under the muscles 
which pass over it at this point, then the rotation outwards will not be 
necessary in any part of the procedure. 

Baron Larrey has reported a case of dislocation " before the hori- 
zontal portion of the pubes," which he reduced " by suddenly raising 
with his shoulder the lower extremity of the femur, while with both hands 
he depressed the head of the bone." 1 This is the same case of which 
we have already spoken as being attended with the unusual phenomenon 
of the thigh placed at a right angle with the body. 

If reduction is attempted by extension, the |patient ought to be laid 
on his back upon a table, with the dislocated limb falling off slightly 
from its side. The extending band, made fast above the knee, should 
then be secured to a staple in the line of the axis of the dislocated thigh, 
and of course below the table ; while the counter-extending band, cross- 
ing under the perineum, should be made fast in the same line, above the 
level of the table, and beyond the head of the patient. 

Fig. 330. 




Keduction of dislocation upon the pubes, by extension. 

When extension is commenced, and the head of the femur has begun 
to move, the reduction may sometimes be facilitated by lifting the upper 
part of the thigh with a jack-towel or a band passed under the thigh 
and over the neck of the surgeon, as we have recommended in both of 
the backward dislocations. It may be found advantageous also to flex 
and rotate the limb after extension has brought the head near the 
socket. 

1 Larrey, Lond. Med.-Chir. Rev., Dec. 1820, p. 500; vol. i., first series, from Bul- 
letin de la Fac. de Med., No. 1. 



ANOMALOUS DISLOCATIONS. 785 



§ 5. Anomalous or Irregular Dislocations, or Dislocations which do not 
properly belong to either of the Four Principal Divisions before 
Described. 1 

(Bigelow regards as " irregular" only those in which there is a com- 
plete disruption of the ileo-femoral ligament.) 

1. Dislocations Upwards. 

Syn. — " Sous-cot yloidiennes ;" Malgaigne. " Sixth dislocation ;" Mutter. 

Subspinous. — Malgaigne affirms that the head, in this dislocation, is 
situated external to the anterior inferior spinous process, and about one 
inch below the anterior superior spinous process. 

The symptoms which characterize this accident are shortening of the 
limb, slight abduction and extension, with rotation outwards. The ever- 
sion of the toes, together with the slight amount of shortening which has 
in general been observed, has led several times to the supposition that it 
was a fracture of the neck of the femur ; but the rigidity, and the posi- 
tion of the trochanter and head will usually render the diagnosis clear. 

The following was probably an example of the subspinous disloca- 
tion: — 

Bennett Morris, set. 51, was thrown backwards, in wrestling, in 1851. 
He felt a snap in the hip-joint, and found his thigh placed in a position 
of moderate abduction, so that he could not get his knees together. 
He was able to walk, but not without limping. This condition continued 
three years, during which time he was constantly lame, and suffered 
much pain when walking. 

At the end of this period, when in the act of jumping from his wagon, 
his horses having become frightened, he felt a snap, and at once the 
complete functions of the joint were restored. He could w^alk without 
pain or halt, and he could bring his knees together. Three months 
later, while ascending a flight of steps, carrying a heavy weight, his 
foot slipped, and the luxation was reproduced, and in this condition it 
remained up to the period at which he consulted me, Oct. 1869. I 
found the thigh apparently elongated, but upon measurement it was 
found shortened half an inch. It was moderately abducted and rotated 
outwards. All the motions of the joint were restricted. 

Although I felt very confident that the reduction could be again ac- 
complished, the patient left without permitting me to make the attempt. 

Patrick Coleman, set. 52, was admitted toBellevue Hospital, Dec. 31, 
18T5, with a dislocation of the right femur upwards. He had fallen 

1 Malgaigne, Traite des Frac. et des Lux., torn. ii. p. 869 et seq. Samuel Cooper, 
First Lines, vol. ii. p. 391. Pirrie's Surg., Amer. ed., 1852, p. 275. Skey's Surg., 
Amer. ed., 1851, p. 110 et seq. Gibson's Surg., sixth American ed., vol. i. p. 386. 
Guv's Hospital Reports, vol. i. 1836, pp. 79 and 97 ; vol. iii. 1838, p. 163. London 
Lancet, Loud, ed., vol. i. 1848, p. 184 ; vol. ii. 1840, p. 281 ; vol. i. 1845, p. 412 ; vol. 
ii. p. 159. London Med. Gaz., vol. xix. pp. 657 and 659 ; vol. x. p. 19 ; vol. xxxiii. 
p. 404. Med.-Chir. Trans., vol. xx. p. 112. Lente's paper on "Anomalous Disloca- 
tions of the Hip-joint," in New York Journ. Med. for Nov. 1850, p. 314 et seq. Phil- 
adelphia Med. Examiner, No. 51. Amer. Journ. Med. Sci., vol. xvi. p. 14. New- 
York Med. and Phys. Journ., 1826, vol. v. p. 597. New York Journ. Med., Jan. 
1860, Dr. Shrady's case. Dislocation of the Hip, by Jacob J. Bigelow, M.D., 1869. 



786 DISLOCATIONS OF THE THIGH. 

nine feet into a cellar. Dr. Erskine Mason, in whose ward the patient 
was received, called my attention to him a few hours after the in- 
jury was received. The limb was shortened one-fourth of an inch, as 
nearly as we could ascertain ; strongly everted, or rotated outwards, but 
hanging parallel with the other when he was standing, the right foot 
being a little in advance of the left. The head of the bone could be 
seen and felt below and to the inside of the anterior superior spinous 
process. The trochanter major was turned back, and there was a deep 
depression over it. The limb could be slightly adducted, but in all other 
directions it was immovable. 

After several ineffectual attempts at reduction, under ether, it was 
finally reduced by simple extension. 

March 27, 1877, Michael Munroe, set. 62, was admitted into the New 
York City Hospital with a dislocation of the left femur upwards and for- 
wards upon the ilium. Dr. Charles M. Allin, one of the visiting sur- 
geons, made some efforts at reduction on the same day, but failed. On 
the following day, in the presence of several medical gentlemen, including 
myself, Dr. Allin repeated his efforts more systematically, and was suc- 
cessful. 

Examining the limb while the patient was on his back, and under the 
influence of ether, preparatory to the operation, I found it shortened 
half an inch, strongly everted, and the thigh slightly flexed, but hying 
nearly parallel with the other. The thigh could be adducted quite 
freely, but in all other directions motion was more limited. With some 
difficulty it could be flexed to a right angle with the body. The head 
could be distinctly felt, but not seen, directly below the anterior superior 
spinous process ; and from this position it was occasionally moved, while 
manipulating, farther forwards, but never fairly upon the pubes. The 
patient was a spare man, and not very muscular. 

The accident was caused by stumbling while ascending a flight of 
steps, and falling upon his knees and face. The skin over the spine of 
the tibia was much bruised and scratched. 

Dr. Allin made an attempt at reduction, 1st, by flexing the thigh at a 
right angle, and rotating outwards forcibly. This was unsuccessful. 
2d. By flexion and rotation inwards. 3d. By extension in several 
directions by the hands, including vertical extension, with the thigh 
flexed upon the body. 4th. Compound pulleys were attached to a lacque 
above the knee, and counter-extension was made by a folded sheet 
passed under the perineum, and secured to a staple ; the direction of 
extension being a little back from the line of the axis of the body, as 
recommended by Sir Astley Cooper. A jack-towel was placed under 
the upper part of the thigh, by which this part of the limb was lifted 
upwards and outwards ; a folded sheet also being carried across the 
pelvis to render it steady. The extension was now gradually increased, 
and the limb was from time to time rotated and otherwise manipu- 
lated, so far as its condition of restraint would permit, until it seemed 
probable that this method was to fail also, and the patient having 
been under the influence of ether nearly an hour. 5th. While the ex- 
tension was extreme, the cord was cut by a quick stroke of an ampu- 
tating knife ; and immediately after, while the limb was lying paralyzed 



ANOMALOUS DISLOCATIONS 



<8i 



by the " shock," Dr. Allin seized the thigh, raised the knee a little, 
rotating it inwards, when the head fell easily into its socket. 1 

Other surgeons have met with examples of the subspinous dislocation 
in which the patients have been able to walk quite well immediately 
after the accident. Bigelow supposes that in these cases the upper por- 
tion of the capsule has been completely torn from the margin of the 
acetabulum, and that the head has been permitted to ascend until it was 
arrested by the under surface of the ilio-femoral ligament at the point 
where it rises from the anterior inferior spinous process of the ilium. 

Supraspinous. — Cummins reports a case which occurred in the prac- 
tice of Gibson, of New Lanark, where the head of the bone was believed 
to be situated just above the anterior inferior spinous process and below 
the anterior superior spinous process ; and also a little inwards toward 
the pubes. The limb was shortened fully three inches ; the toes everted ; 
adduction and abduction were exceedingly painful and difficult, but 
flexion was more easily performed. The head of the bone could be felt 
in its new position, especially when the thigh was moved. At first it 
was supposed to be a fracture, but this error having been corrected, the 
surgeons proceeded to attempt reduction on the eleventh day. Exten- 
sion was made by pulleys, and 

when the head of the bone had FlG - 331 - 

descended to the margin of the ^^^ 

cavity, Mr. Gibson lifted the 
upper end of the femur by 
means of a towel, at the same 
moment pressing the knee to- 
ward the opposite thigh, and 
forcibly rotating the limb in- 
wards ; by which means the re- 
duction was accomplished. 2 

Lente has seen the head of 
the femur in the same posi- 
tion as in the case reported 
by Cummins, not as a primi- 
tive dislocation, but consequent 
upon an attempt to reduce a 
dislocation into the ischiatic 
notch. The shortening was 
about two inches ; the limb 
very much rotated outwards ; 
the rotundity of the affected hip 
greater than that of the other, 
and the trochanter major one inch farther removed from the anterior 
superior spinous process. The head of the bone could be felt distinctly 
in its new position. 




Supraspinous dislocation. (From Bigelow. 



1 Brief report of same case, as a " supra-pubic" dislocation, in Archives of Clini- 
cal Surgery, April 15, 1877, p. 38. 

2 Cummins, Guy's Hospital Reports, vol. iii. p. 163, 1838. 



788 DISLOCATIONS OF THE THIGH. 

The reduction was effected finally with pulleys, by the aid of chloro- 
form, and by rotation of the limb in various directions. 1 

Morgan also reports a case in which the head of the femur was above 
the acetabulum, and a little to the outside of the ilio-pectineal eminence. 2 

Some of these dislocations have been reduced by manipulation alone, 
or by manipulation aided by pressure. The limb should be seized in 
the usual manner, at the knee and ankle, carried up toward the face, 
abducted, then rotated inwards, gently adducted, and finally brought 
down again to the bed. At the moment when the rotation and adduction 
commence, the head of the bone should be pressed toward the socket by 
the hands, and, if necessary, lifted a little over the margin of the aceta- 
bulum, by moderate extension at a right angle with the body. Others 
have been reduced easily by extension alone after a thorough trial of 
manipulation. 

Anterior Oblique Dislocation. — Bigelow, who, as has already been 
stated, regards as irregular only those which are accompanied with a 
complete rupture of the ilio femoral ligament; but whose classification in 
that regard I am not fully prepared to adopt ; has nevertheless given us 
the most intelligible and most probable explanation of the mechanism of 

Fig. 332. 




"Anterior oblique dislocation." (From Bigelow.) 

these irregular upward dislocations, and of several other forms of irre- 
gular dislocations. According to this writer, the " anterior oblique dis- 
location," in which the limb is found greatly adducted, and at the same 
time strongly everted, is a regular dorsal dislocation, the head being ad- 
vanced upon the dorsum to a point near the anterior margin of the ilium. 
If now the limb be brought down, the neck of the femur will be made to 
bear against the outer fibres of the ilio-femoral ligament, and as these 
gradually give way the head will become more and more hooked over the 
remaining fibres of the ligament, and above the inferior spinous process 
(" supraspinous") ; or, continued efforts being made to straighten the 
limb, the ligament will give way entirely, and the femur will assume the 
position indicated by the dotted lines (Fig. 331). 

» Lente, New York Journ. of Med., Nov. 1850, p. 314. 

2 Pirrie's Surgery, p. 276. See also Phil. Med. Exam., No. 51, Mutter's paper. 



ANOMALOUS DISLOCATIONS. 789 

• Bigelow recommends a plan of treatment essentially the same as that 
hitherto recommended by myself. " The anterior oblique dislocation 

Fig. 333. 




Mechanism of " anterior oblique dislocation." (From Bigelow.) 

may be reduced by inward circumduction of the extended limb across the 
symphysis, with a little eversion, if necessary, to disengage the head of 
the bone. Inward rotation then converts this into the common luxation 
upon the dorsum." 

2. Dislocations Bowmvards and Backwards upon the Posterior Part of 
the Body of the Ischium , between its Tuberosity and its Spine. 

James C, set. 35, was admitted to the Pennsylvania Hospital, on the 
23d of January, 1835, under the care of Dr. Hewson. The patient, 
a muscular man, had been crushed under a falling roof, and, as he 
thought, with his right thigh separated from his body. When received 
into the hospital, one hour after the accident, the right thigh was flexed 
upon the pelvis, and rested upon the left ; the right leg was also flexed 
upon the thigh ; the knee was below its fellow, the toes turned inwards, 
and the whole limb shortened at least one inch. The head of the bone 
could be felt distinctly resting upon that portion of the ischium which 
lies between the acetabulum, the tuberosity of the ischium, and the 
spine. 

On the following day, the muscles of the patient having been suffi- 
ciently relaxed by suitable means, the pulleys were applied ; but, after 
a second attempt, some of the bands having given way suddenly, the 
pulleys were removed, when it was found that the reduction had been 
accomplished, although neither the patient nor his attendants had 
noticed the return of the bone to its socket. For several days there 
was entire loss of sensibility and motion in the leg, owing probably to 
the pressure which had been made upon the sciatic nerve ; but these 
symptoms gradually disappeared, and at the time when the case was 



790 DISLOCATIONS OF THE THIGH. 

reported, about two months after the accident, he was walking with 
crutches. 

Dr. Kirkbride, who reported this unusual case of dislocation, doubted 
whether the extension was necessary to the reduction, as the head of 
the bone was brought very near the margin of the acetabulum by lifting 
the thigh with a towel, and it probably afterwards entered the socket 
as soon as the extension was relaxed. 1 • 

Malgaigne has referred to several similar examples. 

3. Dislocations Downwards and Bachivards into the lesser or lower 

Ischiatic Notch. 

Syn. — "Behind tuber ischii ;" Gibson, S. Cooper. " Fifth dislocation ;" Gibson. 

September 7, 1821, Charles Lowell, of Lubec, Mass., was riding a 
spirited horse, when the animal, being restive, suddenly reared and 
fell back on his rider, in such a manner that the weight of the horse 
was received on the inside of the left thigh ; Mr. Lowell having fallen 
on his back, a little inclined to the left side. The surgeon, who was 
immediately called, recognized it as a dislocation, and thought he had 
succeeded in reducing it; but a day or two later it was seen by a second 
surgeon, who declared that it was still out of place, and repeated the 
attempt at reduction, but without success, as the result proved. 

In December of the same year Mr. Lowell called upon Dr. John C. 
Warren, of Boston, who was now able to determine, easily, as he 
affirms, the precise character of the accident. The limb was elongated, 
contracted, and the head could be felt in its unnatural position. By 
advice of Dr. Warren, he was taken to the Massachusetts General 
Hospital, and a persevering attempt was there made to reduce the 
bone, but with no better success than had attended the efforts previously 
made . 2 

Mr. Keate has reported a case produced in a very similar way by 
a horse having fallen backwards with the rider into a deep and narrow 
ditch ; but the position of the limb was somewhat extraordinary, con- 
sidering that it was a dislocation backwards, the whole limb being 
very much abducted and the toes being turned outwards, as if the 
head of the bone was in front of the tuber ischii, rather than behind it. 
The thigh and leg were much flexed, and the whole limb was short- 
ened from three to three and a half inches. The head of the femur 
could be distinctly felt " inferior to the ischiatic notch, and on a level 
with the tuberosity of the ischium." In the first attempt at reduction the 
head of the bone was thrown into the foramen thyroideum, from which 
it was, however, after one or two more attempts by extension, and by 
lifting with a jack-towel, restored to the socket. Mr. Keate believes 
that the dislocation was originally into the foramen ovale, but that in 

1 Kirkbride, Amer. Journ. of Med. Sci., vol. xvi. p. 13. 

2 New York Med. and Phys. Journ., vol. v. p. 597, 1826. Letter to the Hon. Isaac 
Parker, etc., by John C. Warren, 1826. North Amer. Med. Journ., vol. iii. p. 169. 



ANOMALOUS DISLOCATIONS. 791 

the struggles made by the patient to extricate himself, it was thrown 
backwards into the position in which he found it. 1 

Mr. Wormald has reported a primitive accident of the same kind, 
occasioned by jumping from a third-story window. The patient died 
soon after, and at the autopsy the head of the femur was found under 
the outer edge of the glutgeus maximus, projecting through the torn 
capsule opposite the upper part of the tuber ischii. The shaft of the 
femur lay across the pubes, and the limb was considerably shortened 
and turned inwards. 2 

4. Dislocations Directly Doivniuards. 

Syn. — " Sous-cotyloi'diennes ;" Malgaigne. 

The following is one of several similar examples now upon record : — ■ 
A man, set. 50, was admitted into the London Hospital under the 
care of Mr. Luke. A dislocation of the left femur was easily diagnos- 
ticated, but the symptoms were peculiar, inasmuch as the limb was 
lengthened one inch, without either inversion or eversion ; yet the 
head of the bone could be easily felt, and was thought to be in the 
ischiatic notch. By manipular movements reduction was easily effected 
about an hour after the accident. The man subsequently died from 
the effects of broken ribs. At the autopsy, Mr. Forbes, the house- 
surgeon, before dissecting the parts, again dislocated the bone. This 
was done with ease, and it was clear that the original form of disloca- 
tion had been reproduced, as the bone could not be made to assume 
any other position. The head of the bone proved to be displaced 
neither into the ischiatic notch nor the thyroid hole, but midway be- 
tween the tw r o, immediately beneath the lower border of the acetab- 
ulum. The gemellus inferior and the quadratus femoris had been torn, 
the ligamentum teres had been wholly detached, and there was a lacera- 
tion in the lower part of the capsular ligament. 3 

Dr. Blackman, of Cincinnati, informs me that, in January, 1859, he 
reduced a subcotyloid, incomplete dislocation, in a man set. 70, by man- 
ipulation, Dr. Judkins lifting the thigh upwards and outwards by means 
of a towel, Avhile Dr. Blackman first flexed and then abducted the limb. 

5. Dislocations Forwards into the Perineum. 

Syn. — " Perine'ales ;" Malgaigne. " Luxation sur la branche ascendante de l'is- 
chion ;" D'Amblard. " Inwards on the ramus of the os pubis ;" Skey. 

D'Amblard published an example of this accident in 1821, occasioned 
by a violent muscular exertion made by the patient in an effort to spring 
into his carriage, the symptoms attending which did not differ materially 
from those which were found to be present in the three following exam 

1 Amer. Journ. Med. Sci., vol. xvi. p. 226, 1835 ; from Lond. Med. Gaz., vol. x. p. 
19. 

2 Wormald, London Med. Gaz., 1836. 

3 Luke, Med. News and Library, vol xvi. p. 34, March, 1858; from Med. Times 
and Gaz., Jan. 2, 1858. 



792 DISLOCATIONS OF THE THIGH. 

pies, except that in the first case the toes were turned slightly inwards, 
while in each of the other cases they were turned outwards. 1 

Mr. E., set. 35, a calker by occupation. The injury was received 
while at work under the bottom of a canal-boat, July 20, 1831, the boat 
being raised upon props three and a half feet long. The patient was 
standing very much bent forwards, with his feet far apart, between which 
lay a piece of round timber one foot in diameter, when the props gave 
way, letting the whole weight of the boat upon himself and his com- 
panions. One of the workmen was killed outright. On extricating Mr. 
E. from his situation, the left leg and thigh were found extended at a 
right angle with the body, the toes turned slightly inwards, the natural 
form of the nates was lost, and the head of the femur could be felt dis- 
tinctly moving, when the limb was rotated, in the perineum, behind the 
scrotum, and near the bulb of the urethra. 

For the purpose of reduction, the patient was laid on his back upon 
a table, and the pelvis made fast by a muslin band. Extension, accom- 
panied with moderate rotation, was then made in a direction outwards 
and downwards, bringing the head of the bone over the ascending ramus 
of the ischium, beyond which it was lying, into the foramen thyroideum ; 
and from this position the bone was replaced in the acetabulum, by car- 
rying the dislocated limb forcibly across the opposite one. The patient 
soon recovered the use of the joint. 2 

J. B., an Irishman, eet. 40, on entering the St. Louis Hospital, gave 
the following account of his accident, which had occurred six hours pre- 
viously: He w r as engaged in excavating earth, and having undermined a 
bank, it unexpectedly fell upon his back while he was standing in a bent 
position, with his thighs stretched widely apart. The weight crushed 
him to the earth, breaking both bones of his right leg, the radius of the 
same side, and dislocating the left hip into the perineum. The thigh 
presented a peculiar appearance, being placed quite at a right angle with 
the body, but somewhat inclined forwards. The part of the hip naturally 
occupied by the trochanter major presented a depression deep enough to 
receive the clenched fist ; while the head of the bone could be both seen 
and felt projecting beneath the skin of the raphe in the perineum. Ro- 
tation of the limb, which was difficult and excessively painful, rendered 
the position of the head still more manifest. The patient had also re- 
tention of urine, occasioned probably by the pressure of the femur upon 
the urethra. Having dressed the fractures, Dr. Pope placed the patient 
under the full influence of chloroform, and then proceeded to reduce the 
dislocated thigh ; for which purpose " two loops were applied, interlock- 
ing each other in the groin, and using the leg as a lever, extension, by 
means of the pulleys, was made transverely to the axis of the body. A 
steady force was kept up for a short time, and the thigh-bone glided into 
its socket with a snap that was heard by every attendant and patient in 
the large ward." 3 

1 Malgaigne, op. cit., torn. ii. p. 876. 

2 W. Parker, New York Med. Gaz., 1841 ; N. Y. Journ. Med., March, 1852, p. 188. 

3 Pope, St. Louis Med. and Surg. Journ., July, 1850 ; N. Y. Journ. Med., March, 
1852, p. 198. 



ANCIENT DISLOCATIONS OF THE FEMUR. 793 

A man, set. 22, was admitted to the Toronto Hospital, under the care 
of Dr. E. W. Hodder, January 15, 1855, having been injured by the 
fall of a bank of earth an hour before. The head of the right femur 
was found under the arch of the pubes, the neck resting upon the ascend- 
ing ramus. The thigh formed nearly a right angle with the body; be- 
ing strongly abducted, and the toes were slightly everted. On the fol- 
lowing day, the patient being placed under the influence of chloroform, 
extension and counter-extension were employed in the direction of the 
axis of the femur, that is, nearly at right angles with the body, while, 
at the same moment, the upper portion of the femur was lifted by a round 
towel. By this manoeuvre the head of the bone was carried into the 
foramen thyroicleum. The force was now applied in a direction "more 
upwards and outwards ; the ankle held by the assistant was drawn under 
the other and at the same time rotated." In a few minutes the com- 
plete reduction was accomplished. His recovery was steady, and three 
weeks later he was discharged, being able to walk very well with the aid 
of a cane. 1 

§ 6. Ancient Dislocations of the Femur. 

Says Sir Astley Cooper: " I am of opinion that three months after 
the accident for the shoulder, and eight weeks for the hip, may be fixed 
as the period at which it would be imprudent to attempt to make the re- 
duction, except in persons of extremely relaxed fibre or of advanced age. 
At the same time, I am fully aware that dislocations have been reduced 
at a more distant period than that which I have mentioned; but in many 
instances the reduction has been attended with the evil results which I 
have just been deprecating." A remark which later surgeons do not 
seem always to have correctly understood, or which, if they have under- 
stood, they have not correctly represented ; since it has many times been 
affirmed of this distinguished surgeon, that he regarded reduction of the 
hip as impossible after eight weeks, and they have proceeded to cite 
examples which would prove that he was in error. But long before Sir 
Astley's day, Gockelius mentioned a case of reduction of the femur 
after six months, and Giulio Saliceto declared that he had reduced a 
similar dislocation after one year, 2 and Sir Astley says that he is 
" fully aware" of the existence of such facts or statements ; yet with a 
knowledge of what has so frequently followed these attempts, he would 
not recommend the trial after eight weeks, except under the circum- 
stances by him stated ; and notwithstanding the number of these re- 
ported successes has been considerably increased in our day, we suspect 
that Sir Astley's rule will continue to govern experienced and discreet 
surgeons. Certain examples which have recently been published of suc- 
cessful reduction after six months by manipulation, if sufficiently verified, 
would encourage a hope that the period might be greatly extended, were 
it not that manipulation also has already failed many times in the case 

1 Hodder, British. Amer. Journ., March, 1861. 

2 Malgaigne, op. cit., torn. ii. p. 185 ; from Gallicinium Medico-practicuni, Ulm, 
1700, p. 288. 

51 



794 DISLOCATIONS OF THE THIGH. 

of ancient luxations, and that the attempt has sometimes been followed 
with disastrous results, even in recent cases. 

I will describe some of the reported examples of reduction by manipu- 
lation after the lapse of six months: — 

The following case w T as published in the first edition of this treatise, 
but I regret that I am now unable to say from what source my informa- 
tion was then obtained, and communications addressed by me to gentle- 
men in Havana have failed to trace the case to its original source. It 
will be observed, however, that there is no history of the accident which 
caused the dislocation, and its existence was not suspected until the 
patient arose after an illness which had confined him to his bed for a 
month or more. It was reduced without anaesthesia ; it was three or 
four times reluxated, notwithstanding the employment of judicious means 
to keep it in place, and while the patient was in bed ; that it w r as re- 
duced with a snap, "deeper than is ordinarily observed in the reduction 
of recent dislocations ;" and, finally, when the patient was dismissed it 
is only said, he was able to walk without crutches. In short, a careful 
reading of the report must convey to the experienced surgeon a suspicion 
that it may not have been correctly diagnosticated, and that, if it was, 
its reduction may not have been thoroughly accomplished and perma- 
nently maintained. 

A Chinese boy, named Ah-sin, aged about sixteen years, arrived at 
Havana on the 4th of June, 1856, suffering under a severe illness, which 
confined him for a month or more to his bed, and the existence of the 
dislocation was not discovered until he had sufficiently recovered to rise 
upon his feet. It was then ascertained that he had a dislocation of the 
left femur upon the dorsum ilii. Upon inquiry, Dr. Martial Dupierris, of 
Havana, learned that the accident had occurred before leaving China, a 
period of more than six months. The boy was still feeble, the limb some- 
what emaciated, and instead of being rigid from muscular contraction, all 
the muscles " were in a flaccid condition, except the great gluteal, which 
was painful to the touch." Deeming the use of anaesthetics improper, on 
account of the boy's feeble condition, these agents were not employed. Dr. 
Dupierris describes the method of reduction as follows : " The body being 
held by two assistants by means of two bands, one of which passed be- 
neath the perineum, and the other under the axillae, traction was made 
upon the limb by two strong and intelligent assistants. The movement 
of the head of the bone, resulting from this manoeuvre, was very limited, 
even when the force was much increased ; and the excruciating pain, 
which the patient referred to the iliac region, compelled us for the mo- 
ment to desist. 

" The following day, the patient having obtained a tolerable night's 
rest by means of a narcotic potion, I concluded to attempt the reduction 
by flexion, believing that I could thus better prevent any accident which 
the necessary force might produce; the operator, in adopting this 
method, having it in his power to follow the head of the bone by pressure 
upon it with the hand, aiding its movement in the proper direction, or 
correcting any deviation that may occur. The emaciated condition of 
the boy was eminently favorable for such a procedure. 

" The patient being placed upon his back, and the trunk of the body 



ANCIENT DISLOCATIONS OF THE FEMUR. 795 

made steady by assistants, with the left hand I grasped the upper part 
of the leg, placed the right hand upon the head of the bone in the iliac 
fossa, and then proceeded to flex the leg upon the thigh, and the thigh 
upon the pelvis. By this movement the great gluteal muscle was re- 
laxed, and the head of the bone advanced, while with the right hand I 
directed the latter toward the cotyloid cavity. As soon as I judged the 
head to be immediately above the centre of the socket, I extended the 
leg, the thigh remaining flexed at a right angle ; and then using the 
limb as a lever, I rotated it from within outwards, and at the same time 
extended it by making a movement of circumduction in a similar direc- 
tion. When, by these procedures, the limb was brought near to its 
opposite fellow, a snap audible to the assistants, and of a deeper charac- 
"ter than is ordinarily observed in the reduction of recent dislocations, 
indicated the return of the head of the bone to its natural position ; a 
fact which was further substantiated by the establishment of the original 
length and form of the member and the subsidence of the pain. 

" The after-treatment consisted in placing a pad between the knees, 
and another between the internal malleoli, and confining the limbs to- 
gether by two bands, one above the knees, and the other around the 
lower part of the legs. But in spite of these precautions to prevent re- 
displacement, the next morning I found that the dislocation had been 
reproduced. It was again reduced, but for three successive days there 
was a redisplacement. After this, however, the head of the bone kept 
its place ; passive motion was daily employed, and all suffering ceased. 
After twenty days of rest, and a liberal use of the lactate of iron, the 
patient was allowed to get up ; and, being provided with a pair of 
crutches, upon which he exercised himself daily, improved very rapidly. 
The muscles gradually recovered their bulk and vigor, and at the end of 
forty-eight days he was enabled to walk without crutches, although with 
some fear of falling. About the middle of August he was put to work 
in a cigar manufactory, and has continued well ever since." 

The case reported by Guyenot, of a young woman twenty-two years 
of age, in which Cabanis is said to have accomplished reduction after 
the dislocation had existed two years, was probably an example of chronic 
hip disease. Indeed, Malgaigne has placed it in this category, although 
by other writers, including Sir Astley, it has been spoken of as if it had 
been traumatic. It is said that the reduction was effected in 1768, but 
Guyenot does not say that he was present when it was done, nor is there 
anything in the report of the case to render it certain that it was actually 
dislocated, or if dislocated that it was ever reduced. 1 

Nor is it proper to accept of the accidental reduction of the femur, 
reported to Sir Astley Cooper by Mr. Cornish, as a well-authenticated 
case. Indeed, Sir Astley himself questions the accuracy of the report. 2 

Dr. Lewis A. Sayre, in a paper read before the American Medical 
Association, has reported a case of pathological dislocation, into the ischi- 
atic notch, of nine months' standing, which he claims to have reduced ; 3 

1 Mem. de l'Acadernie Royal de Chirurgie de Paris, torn, cinquieme, p. 803. 

2 Sir Ast. Cooper, Frac. and Dis., 2d Lond. ed., p. 101. 

3 Sayre, Case of Luxation of Femur into Ischiatic Notch, of nine months' standing, 
Reduced by Manipulation, Trans. Amer. Assoc, 1866, p. 263. 



796 DISLOCATION'S OF THE THLGH, 

and which I would not deem it necessary to allude to in this place, ex- 
cept that in commenting upon the opinions of others he seems to regard 
it as a case of traumatic dislocation, although he does not specifically 
state that it was ;• and that, having stated in his report that I was pres- 
ent, he has rendered it necessary that I should express my own views of 
the case and of the facts. 

The patient, Lieut. -Col. William A. Bullit, was wounded in battle, 
May 9, 1864, in two places, the first ball entering five inches below the 
anterior superior spinous process of the ilium, and remaining. He fell 
after the second shot, but he " rose immediately and Avalked half a mile 
to the rear." Several attacks of erysipelas ensued, followed by abscess, 
one of which formed in the left iliac fossa. More than five months 
after the injury he, for the first time, turned from his back to his side, 
and in doing so he felt " a slipping of the caput femoris. This occurred 
almost daily for two weeks, when, dislocation being recognized, Dr. 
McDermott, assisted by Drs. Coolidge and Goldsmith, U. S. A., at- 
tempted to reduce it under ether, but failed. u In the latter part of 
February, 1865, four months after dislocation," another attempt was 
made to reduce it, under chloroform. The fact that this was not a trau- 
matic dislocation, dating from the period of the original injury, is thus 
confirmed by Dr. Sayre himself, for it was already more than nine 
months since he had been wounded, but the dislocation had taken place 
only four months previous. At this time the attempt at reduction was 
made by Professor Cook, assisted by Drs. Force, Cox, Gait, and Garvin, 
all of Louisville, Ky. This attempt failed also. July 20, 1865, Dr. 
Sayre, in the presence of several gentlemen, including myself, the 
patient being under chloroform, forcibly broke up some adhesions and 
Drought the limb, which was flexed upon the pelvis, down to a position 
nearly but not quite parallel with the other, and there secured it with 
a weight and pulley. There was no claim at the time, so far as I know, 
that a restoration of the bone to its socket had been effected. Some 
months later I saw this gentleman standing with a high heel under the 
boot corresponding to the lame leg, and I was then informed, in reply to 
my inquiry, that the dislocation was not reduced, but that, as I could 
see, the position of the limb was greatly improved. 

In Dr. Sayre's report of the case he does not state when the disloca- 
tion was reduced, and certainly it was not reduced in my presence : and 
I have no reason to suppose that it was subsequently. 

In closing his report Dr. Sayre takes exceptions to Dr. Gross's state- 
ment that " chronic" dislocations demand some preliminary treatment 
before attempting reduction to insure success, without noting the fact 
that the distinguished author was speaking then only of traumatic dis- 
locations, but adding, in italics, " my belief is that the best time to per- 
form such an operation is when you find it necessary to be done." 

The editor of the Western Lancet, published in Cincinnati, mentions 
in a few lines (vol. xvii. p. 253, April, 1856), that on the 22d of March 
preceding Dr. Blackmail, a distinguished surgeon of that city, had re- 
duced, at the Commercial Hospital, a dislocation of the femur upon the 
dorsum ilii, under chloroform, of six months' standing. No particulars, 
or authority for the statement are given. Two months later this editorial, 



ANCIENT DISLOCATION'S OF THE FEMUR. 797 

or a copy of it, appeared in the Ohio Medical and Surgical Journal 
(vol. xviii. p. 522) without additional remarks or information. So far 
as I know this is the only published account of the case. In reply to 
my note of inquiry, addressed to Dr. Blackmail subsequently, he stated, 
April 21. 1859, that the patient presented himself before the class 
" about six months since, and the restoration of the functions of the 
limb was found to be complete." Since the death of Dr. Blackmail, 
hoping to obtain a more complete history of the case, I wrote to a. gentle- 
man in Cincinnati, who informed me that no farther history could be 
obtained, as the hospital record for that year was lost. 

Dr. George E. Post, Missionary in Syria, and a Professor in the 
Protestant College, at Beiiiit, has reported a remarkable case of disloca- 
tion of both hips in a native girl, thirteen years old, " the result of a 
vis a tergo, applied six months previous" to her admission to the hospital. 
The force applied to her back caused her to fall forward, with a u twist- 
ing of the trunk to the right, and the lower extremities to the left." 
She was admitted Jan. 20, 1877. At this time it was ascertained that 
she had a dislocation not only of the left femur, but that there was a 
fracture of the neck also on the same side ; the head had become 
necrosed, and there was a sinus communicating with the head as it lay 
upon the dorsum ilii. An incision was made, and the dead bone was 
removed. The anchylosed knee and thigh were then straightened by 
brisement force, the restoration being accompanied with a good deal of 
laceration. 

" The left lower extremity was then committed to an assistant, while 
the requisite manipulations were undertaken to reduce the dislocation of 
the right hip. This was effected without pulleys, adding another to the 
many proofs that bone setting is a matter of address and attention to 
anatomical relations rather than to force." The patient recovered after 
a prolonged confinement, and at the last accounts was able to walk with 
crutches, the function of the right limb being fully restored, and the left 
being shortened four and a half inches. 1 

It is unnecessary to say that the mode of production of this double 
dislocation was extraordinary, and that the facility with which the right 
hip was reduced at the end of six months was equally extraordinary : 
and that for these reasons the distinguished operator owed it both to 
himself and to the profession to supply a more complete history of the 
case, symptoms, and treatment than he has given. In so far as the cause 
and the mode of reduction are concerned, I have given my readers all 
that the report contains. 

The case reported by Bigelow, of reduction after three months, must 
be rejected also as a traumatic dislocation. Dr. Bigelow says himself 
that it was " perhaps connected with hip disease," as there was evidence 
of disease in the joint for some time prior to the accident which was sup- 
posed to have caused the dislocation, and its subsequent existence was 
demonstrated by sinuses which formed and opened in the groin. He 
had also had for a long time disease of the bone near the ankle. 2 

1 Post, Med. Record, May 11, 1878, p. 366. 

2 Bigelow, Disloc. and Frac. of Hip, 1869, p. 111. 



798 



DISLOCATIONS OF THE THIGH. 



Dr. Brown's case of reduction of ancient dislocation of the femur in 
a child eight years old, cannot be considered in this connection, inas- 
much as he states that the dislocation was probably caused by chronic 
rheumatic arthritis. 1 

In the following table I have inserted such cases as have up to the 
present moment the best claim to be regarded as actual reductions of 
ancient traumatic hip-joint dislocations. Some of them, however re- 
markable they may seem to be, there exists now no satisfactory means 
of verifying or of disproving. Others, even among those reported by 
my contemporaries, are so briefly and imperfectly reported that they do 
not seem to me thoroughly established — certainly not by that sort of 
testimony which science demands where unusual and extraordinary facts 
are recorded. 



Table of Ancient Traumatic Dislocations af the Hip, said to have been 

reduced. 







Age 














of 


Time after 


Form of 


Method of 




No. 


Operator. 


tient 
yrs. 


disloca- 
tion. 


dislocation. 


reduction. 


Keference. 


1 


S. Nott. 


33 


56 days. 


On dorsum 
ilii. 


Extension. 


Sir Astley Cooper, Disloc. and 
Frac, etc. 2d Lond. ed., 
p. 50. 


2 


A. Crosby. 




68 days. 




Extension 
with anaes- 
thetics. 


Trans. Am. Med. Assoc, vol. 
iii. p. 356, An. 1850. 


3 


Breschet. 


... 


72 days. 






Brown, Bost. Med. and Surg. 
Journ., Sept. 29, 1870. 


4 


Dupuytren. 


23 


78 days. 


Dorsum 
ilii. 


Extension. 


Dupuytreil on Diseases and 
Injuries of Bones. London 
ed., 1847, p. 373. 


5 


Kimball. 




3 mos. 






Northwestern Med. and Surg. 
Journ., June, 1870. 


6 


Dupuytreil. 


25 


99 days. 


Dorsum 
ilii. 


Extension. 


Dupuytren, op. cit., p. 375. 


7 


W. L. Atlee. 


... 


4 mos. 


Extension 


Trans. Am. Med. Assoc, vol. 












with anaes- 


iii. p. 357, An. 1850. 












thetics. 




8 


Williams. 


8 


5 mos. 


Probably 

in ischiadic 

notch. 


Anaesthetic 


Lancet, vol. i. p. 665, An. 
1862. 


9 


Gochelius. 




6 mos. 






Gallicinium Med.-pract.,Ulm, 
1700, p. 288. 


10 


Dupierris. 


16 


6 mos. 


Dorsum 
ilii. 


Manipula- 
tion. 




11 


Blackmail. 




6 mos. 






Western Lancet, April, 1856, 
p. 253. 


12 


Bigelow. 


27 


8 mos. 


Dorsum 
ilii. 


Manipula- 
tion . 


Bigelow on Dis. and Frac of 
Hip, 1869, p. 55. 


13 


Smyth. 


27 


9 mos. 


Dorsum 
ilii. 


Manipula- 
tion, with 
anaesthetic 


New Orleans Journ. Med., 
Jan. 1, 1869, p. 71. 


14 


Saliceto. 


... 


1 year. 






Malgaigne, Frac. & Dis. Paris 
ed., 1855, vol. ii. p. 185. 



1 Spontaneous Dislocation on Dorsum Ilii. Reduction after several months, by 
Francis Brown, M.D., etc. A pamphlet. Boston Med. and Surg. Journ., Sept. 29, 
1870. 



ANCIENT DISLOCATIONS OF THE FEMUR. 799 

Accidents in Attempts at Reduction of Ancient Dislocations. — While 
estimating the relative value of the several methods of reduction, I have 
cited several examples of fracture of the neck of the femur in the at- 
tempt to reduce old dislocations. In some cases the results have been 
much more serious. 

A man, 29 years old, was received at La Pitie, Paris, on the 13th of 
May, 1868, with dislocation of the hip of seven months' standing. M. 
Broca attempted to reduce it, using a force of 480 lbs. No reduction 
was obtained, and the patient insisted upon leaving the hospital five 
days afterward. A fortnight then elapsed, when he presented himself 
at another hospital, with the hip enormously swollen, and died the next 
day of peritonitis. The autopsy showed that the head of the bone lay 
in the ischiatic notch, that it was held firmly by bundles of the torn 
capsule, and that the cotyloid cavity was much shrunk. Pus was found 
in the capsule, in the iliac fossa, in the articular cavities, and had found 
its way into the peritoneum, through the obturator foramen. 1 

The following case seems deserving of mention, for the reason that it 
is the first, so far as I am aware, in which an attempt has been made to 
reduce the dislocation after a subcutaneous division of the capsule : — 

Thomas Jordan, aet. 28, of Utica, N. Y., was sent to me by my former 
pupil, Dr. Jenkins, in January, 1869, having a dislocation of his left 
femur upwards and backwards upon the dorsum ilii. His account of the 
case was, that seven months before he was thrown in wrestling ; a sur- 
geon was called on the following day, and finding a dislocation, he 
placed him under the influence of an anaesthetic, and, as he supposed, 
reduced the dislocation by manipulation. 

The case did not come under the notice of Dr. Jenkins until a few 
weeks before he was sent to me, and although the character of the acci- 
dent was recognized, no attempts were made at reduction. 

I found the limb rotated inwards, adducted, and shortened two inches. 
Before the class of medical students at Belle vue, assisted by Drs. Sayre, 
Crosby, Howard, and others, I made an attempt, January 29th, to break 
up the adhesions and reduce the dislocation, the patient being fully 
under the influence of ether. We were able to move the limb quite 
freely in various directions ; but after a trial of nearly an hour, we 
abandoned the attempt, having failed to accomplish reduction. 

A few days later I applied extension,- by means of adhesive plaster 
and a cord, with a weight of twenty pounds. This was continued unre- 
mittingly until February the 24th, when he was again placed under the 
influence of ether before the class. Assisted by Drs. Stephen Smith, 
Howard, Cross, and others, attempts were made to reduce the bone by 
manipulation, but without success. Believing now that the untorn por- 
tion of the capsule, and particularly the ilio-fe moral ligament, constituted 
the chief obstacle to the reduction, I introduced a long, firm, but narrow 
bistoury, which I had had made for the purpose, just above the tro- 
chanter major, carrying its point inward until it touched the neck at the 
base of the trochanter. From this point, the edge of the knife being 
directed towards the head of the bone, I swept the point of the knife 

1 New York Med. Record, Dec. 16, 1868. 



800 DISLOCATIONS OF THE THIGH. 

slowly along until the head was distinctly felt, the point touching the 
neck apparently in its whole length. This was accomplished without 
enlarging the external opening. While the incision was being made the 
limb was kept rotated outwards, and abducted as much as was possible, 
and it was felt to yield distinctly, so that both rotation outwards and 
abduction were more complete afterwards than before. I then divided 
also the tensor vaginae femoris ; and now the attempts at reduction were 
repeated, both by manipulation and extension, but without success. 

The result of this attempt to reduce the dislocation by division of the 
ilio-femoral ligament, although unsuccessful, encourages a hope that it 
may sometimes succeed ; and I shall not hesitate to repeat the experi- 
ment, if a favorable opportunity is presented. 

§ 7. Partial Dislocations of the Femur. 

Malgaigne declares that certain experiments made upon the cadaver 
led him, at one time, to the conclusion that all primitive luxations of the 
femur were incomplete, and that the old complete luxations found in 
autopsies have become so consecutively. Later observations have taught 
him to correct this error, yet he still finds " incomplete backward luxa- 
tions quite common, and incomplete dislocations in all the other direc- 
tions much more common." 

I have more than once found occasion to call in question the accuracy 
of Malgaigne's views in relation to partial dislocations, the relative fre- 
quency of which, as traumatic accidents, he seems constantly disposed 
to greatly exaggerate. I cannot see the propriety of calling those cases 
partial dislocations, in which the head of the bone has fairly left the 
cotyloid cavity, and mounted upon its margin, even if it remains in this 
position without tearing the capsule ; since the articular surfaces are 
now as completely separated as if the capsule had given way, and the 
head of the bone had escaped through the laceration. It is in fact a 
complete luxation. But I doubt very much whether the head of the bone 
ever rests upon the margin of the acetabulum without tearing the cap- 
sule, unless it has previously undergone certain pathological changes, 
such as I have already described ; at least I cannot hesitate to reject all 
those examples in which the head of the femur is supposed to rest upon 
the upper or outer margin of the acetabulum ; and if I permit myself to 
speak of incomplete dislocations at all in this connection, I shall reserve 
the term for those rare cases in which the head of the femur becomes 
engaged in the cotyloid notch, after breaking down the fibrous band 
which, in the natural state, is continuous with the rim of the acetabulum. 

Of this form of dislocation, I think I have met with two examples ; one 
of which was in the person of the boy Lower, already mentioned, whose 
thigh was reduced accidentally by his father ; and the other occurred in 
a boy fifteen years of age, residing at that time in Rutland, Vermont. 
He was brought to me on the 28th of May, 1842, by Dr. Haynes, of 
Rutland, at which time the dislocation had existed five years. His ac- 
count of himself was that in walking upon a slippery floor, his left leg 
slid outwards and backwards in such a manner that when he fell it 
was fairly doubled under his back. On the tenth day following the acci- 



COXO-FEMORAL DISLOCATIONS WITH FRACTURE. 801 

dent he began to walk with some help, and he has continued to walk 
ever since, but with a manifest halt. Three months after the injury was 
received, it was first seen by several surgeons, who pronounced it a dis- 
location, and attempted reduction without mechanical aid, but were 
unsuccessful. 

When the young man was brought to me, the limb was neither length- 
ened nor shortened, but the thigh was forcibly abducted and rotated out- 
wards. It could not be flexed nor greatly extended. The head of the 
femur could be distinctly felt, as it lay anterior to the socket, but not 
sufficiently far forwards to rest upon the foramen thyroideum. 

J. C. Warren, of Boston, has reported a similar example in a child six 
years old, who was brought, April 21, 1841, to the Massachusetts Gene- 
ral Hospital. Dr. Hale, who saw the lad at the end of two weeks, 
thought it a dislocation, but it had been treated by another surgeon as 
a case of hip-disease. The dislocation had now existed eight or ten 
weeks. The limb was a little lengthened, abducted, turned outwards, 
and advanced in front of the body, with very slight motion of either flex- 
ion or extension, and almost no tenderness about the joint. Dr. Warren, 
also, was able to feel indistinctly the head of the bone " immediately 
external to, and in contact with, the insertion of the triceps and gracilis 
muscles." 

An attempt was made by manual extension and manipulation to accom- 
plish the reduction, but without success. 1 

It is probable that both the above cases, which I have described at 
length, were examples of partial dislocations ; yet I cannot conceal from 
others a doubt which I actually entertain whether they were not, after 
all, only examples of hip-joint disease, arrested after having wrought 
certain slight pathological changes in the joint and the tissues adjacent. 
If, however, they were not examples of incomplete dislocations of the hip- 
joint, then I question whether any such cases have ever occurred as 
simple traumatic accidents. 

§ 8. Coxo-Femoral Dislocations, complicated with Fracture of the Femur. 

Such complications are exceedingly rare, but it will not do to deny 
their possibility ; although in some of the cases reported, the testimony 
is so incomplete as to leave a doubt whether the surgeons have not erred 
in their diagnosis. 

James Douglas has reported a case of dislocation upon the pubes, com- 
plicated with a fracture of the neck of the femur, the actual condition of 
which was verified by an autopsy ; the patient having died twelve years 
after the injury was received. The head of the femur still remained 
above the pubes, and was in no way connected with its neck or shaft. 
The upper end of the femur projected in the groin, lying upon the inside 
of the femoral artery and vein. Many other curious pathological changes 
had also occurred. 2 

1 Warren, Bost. Med. and Snrg. Jonrn., vol. xxiv. p. 220. 

2 Amer. Journ. Med. Sci., vol. xxxiii. p. 455, from Lond. and Edin. Month. Journ. 
of Med. Sci., Dec. 1843. 



802 DISLOCATIONS OF THE THIGH. 

The well-authenticated examples of reduction of the dislocation, 
where the femur was broken also, are still more rare ; and several of the 
recorded examples which my researches have discovered, need additional 
confirmation. 

John Bloxham, of Newport, in the Isle of Wight, claims to have 
reduced a dislocation of the femur on the pubes, which was accompanied 
with a fracture of the thigh a little above its middle. The following is 
the account of this interesting case which we find in the London Medico- 
CMrurgical Revieiv, copied from the Medical Grazette of August 24th, 
1833. We regret that we are unable to see the account as published 
in the Grazette, which might supply some circumstances important to a 
full appreciation of the case: — 

On the seventh or eighth day after the accident, "the patient was 
laid on his back upon the bed, and kept in that position by means of a 
sheet passed across the pelvis and fastened to the bedstead; another 
sheet was also passed over the left groin, and secured in a similar 
manner. The dislocated and fractured limb was then inclosed in splints, 
one of Avhich extended up the back of the thigh as far as the tuberosity 
of the ischium. Pulleys, which were secured to a staple in the ceiling, 
placed at the distance of a foot to the right of a point vertical to the 
patient's navel, were then attached to a bandage fastened round the 
splints as high up as possible. 

" The foot was raised with the knee extended, so as to bring the limb 
nearly to a right angle with the line of the tackle, when by drawing 
gradually on the cord, in the course of about ten or fifteen minutes the 
head of the bone was rendered movable, and was brought considerably 
more forward. I then began to press on the head of the bone, so as to 
push it downwards, whilst the pulleys held it partially disengaged from 
the pelvis. In a few minutes the head of the bone passed over the 
ridge of the os pubis, and I then directed the foot to be raised a little 
higher, which by putting the glutei muscles more upon the stretch was 
calculated to render them more efficient in drawing the bone into its 
proper place. By this manoeuvre, the head of the bone was drawn 
backwards, and on the foot being more elevated and the cord slackened, 
it continued to recede from my fingers till the trochanter major made its 
appearance in the natural situation, and the reduction was found to be 
perfectly complete. 

" Lest the head of the bone should slip backwards on the dorsum ilii, 
I directed an assistant to apply firm pressure during the latter part of 
the process, above and behind the acetabulum. 

" The apparatus w r as then removed, the thigh bound up in short splints, 
and the patient laid upon a double-inclined plane. No symptoms of 
inflammation appeared afterwards about the joint. Passive motion was 
employed at the end of a week, and occasionally repeated during the 
whole reparatory process." 1 

Without intending to question the accuracy of the statements in this 
case, which, in the main, seem to bear the marks of credibility, we 
must express our surprise that so little difficulty was experienced in the 

1 Lond. Med.-Chir. Rev., vol. xix. p. 420, Oct. 1833. 



COXO-FEMORAL DISLOCATIONS WITH FRACTURE. 803 

reduction if the femur was actually broken, no more, indeed, than is 
usually experienced when the bone is not broken; and that Mr. Bloxham 
was able to employ safely passive motion at the end of a week. 

Charles Thornhill relates, in the London Medical Gazette for July, 
1836, a case of fracture of the femur through its upper third, in a man set. 
40, with dislocation into the ischiatic notch ; which dislocation, he assures 
us, was reduced at the end of six weeks. But it is much more probable 
that, instead of reducing a dislocation, he refractured the bone. During 
more than one hour and a half, aided by pulleys, tractions and manipu- 
lations were made in almost every direction. 

The upper part of the thigh was lifted with all the strength of one 
man by means of a jack-towel; it was violently rotated, adducted, and 
abducted. Both the perineal and the knee band gave way, from the 
excess of the force employed ; and, finally, the head of the femur 
resumed its place with an audible crash. After which the " limb was 
of nearly equal length with the other;" but there remained an "im- 
mense deposit" around the acetabulum. 1 

Malgaigne says that M. Eteve found a poor fellow with a dislocation 
of his left thigh backwards, a fracture near its middle, a penetrating 
wound of the knee, and a fracture of the fibula in the same leg. With- 
out delay he proceeded to reduce the dislocation by directing tw 7 o 
assistants to support the body, three to support the leg, and two more 
to make extension from a towel tied not very tightly around the thigh 
above the fracture. The leg was then extended upon the thigh, and 
the thigh flexed upon the pelvis until it was at a right angle with the 
body ; and after a gradual extension had been made in this direction, 
M. EteVe pushed with all his strength the head of the bone into its 
socket. Of which case Malgaigne justly remarks, that the " extension" 
practised by the surgeon was only imaginary. 2 If the reduction was 
accomplished at all, it was by manipulation and pressure. 

Finally, Markoe relates, in the paper to which we have already 
several times made allusion, the case of a boy set. 8, who was admitted 
into the New York City Hospital, on the 29th of June, 1853, with a 
compound fracture of the right thigh, a simple fracture of the left, and 
a dislocation of the head of the right femur upwards and backwards 
upon the dorsum ilii. 

When placed upon the bed, the right limb lay obliquely across the 
abdomen of the boy, with the foot resting against the axilla of the 
left side. " The house-surgeon, to whose care the case fell on admis- 
sion, took the injured limb in his hands and very carefully carried it 
over the abdomen to the right side, and then adducted it and brought 
it down toward the straight position," during which procedure the head 
of the bone is supposed to have resumed its place in the socket. 3 

Such is the account furnished of the symptoms and treatment of this 
extraordinary case ; too meagre, certainly, to entitle it to much confidence, 
or to permit us to draw from it any practical inferences. We are not 

1 Amer. Journ. Med. Sci., vol. xxv. p. 218. 

2 Malgaigne, op. cit., torn. ii. p. 206; from Gazette Med., 1838, p. 757. 

3 New York Journ. Med., Jan. 1855, p. 30. 



804 DISLOCATIONS OF THE THIGH. 

even informed what was the name of the young man who alone saw and 
treated the case, nor what was his responsibility as a surgeon. 

I have been unable to find any other examples of fracture of the femur 
complicated with dislocation ; and, rejecting at least Mr. Thornhill's case 
as altogether incredible, the proper conclusion would be, that reduction 
is sometimes possible in recent cases, if the surgeon will resort promptly, 
before swelling and muscular contractions have taken place, to manipu- 
lation combined with pressure upon the head of the bone. Indeed, it is 
probable that pressure alone is the means upon which the success will 
finally depend. Richet says that he has several times dislocated the 
femur in the cadaver ; and then, having sawn off the head so as to re- 
present a fracture, he has always been able to push the head of the bone 
easily into its socket. 1 By seizing the moment then when the patient is 
laboring under the shock, or by placing him completely under the influ- 
ence of an anaesthetic, no resistance will be offered by the muscles any 
more than in the cadaver, and the reduction may, perhaps, be easily 
effected. 

I have no confidence that anything can be accomplished by extension; 
nor do I think it will be best to wait until the femur has united, since 
such delay will probably render the reduction impossible. 

§ 9. Voluntary or Spontaneous Dislocations of the Femur. 

Examples in which persons, having suffered no disease of the hip-joint, 
have been able voluntarily to dislocate the femur, have, from time to 
time, been recorded, but I am not aware that any dissections have ever 
been made in these cases. I shall, therefore, not attempt any explana- 
tion of the facts, but simply record them as matters of curious interest, 
and for the purpose of inducing others to make of them a subject of in- 
vestigation. 

Malgaigne remarks that "certain persons, without having suffered from 
any injury or disease of the joint, have the singular faculty of disloca- 
ting and reducing the femur voluntarily. Portal saw an example in the 
person of the Abb6 of Saint-Benoit. Humbert mentions a surgeon near 
Troves, who dislocated the femur up and down, and reduced it by the 
simple act of the muscles, without the aid of his hands. He reports, 
at the same time, the curious history of a person endowed with the same 
power, who after a quarrel produced the dislocation, and then claimed 
damages, attributing the accident to the violence of his adversary." 
The same author speaks of cases reported by Coulson, Solly, and Stan- 
ley, and the one hereafter to be mentioned alluded to by Sir Astley 
Cooper, making in all seven cases. It does not appear, Malgaigne adds, 
that u this laxity impairs the functions of the limb ; it is nevertheless a 
subject which demands to be better studied." 2 

Sir Astley Cooper says, " I have received from Mr. Brindley, Sur- 
geon, of Wink Hill, an account of a dislocation of the os femoris, which 

1 New York Journ. Med., March, 1854, p. 293 ; from Bullet, de Ther. 

2 Humbert, Essai sur les lux. spontanees du femur, 1835, p. 35. From Malgaigne, 
op. cit., vol. ii. p. 883. He also refers to Graz. des Hopitaux, 1841, p. 104. 



VOLUNTABY DISLOCATIONS OF THE FEMUR. 805 

the patient is able to produce and reduce when he chooses. The man is 
fifty years of age." 1 Sir Astley has not given any further account of 
this case. 

Samuel Cooper speaks of this matter briefly as follows : " There are 
instances recorded of persons who could dislocate the thigh-bone spon- 
taneously, and afterwards replace it again without assistance. A gen- 
tleman, who attended my lectures, informed me of a person so circum- 
stanced, and related some of the particulars to me. I suppose that, in 
such cases, there must be an unusual relaxation of the synovial mem- 
brane, a rupture of the ligamentum teres, and perhaps an imperfect state 
of the acetabulum." 2 

Dr. William Gibson mentions the two preceding cases, and adds, " A 
third was related in an inaugural essay, by Dr. Lewis, of North Caro- 
lina, who graduated at our University (University of Pennsylvania) in 
the spring of 1841. " 3 

Dr. Bigelow has seen two cases, and reports a third from Prof. E. M. 
Moore, of Rochester. In the first of these the hip was at first dislocated 
by an accident ; and in a few hours it was reduced by manipulation. 
Eight days after the accident, in attempting to walk, it was again par- 
tially luxated, when the patient himself replaced it by pushing against it 
with the hand, and pressing with the other against the knee. Since then 
the man has been able to dislocate the bone backward upon the edge of 
the socket by muscular action, and to reduce it by throwing the leg out 
sideways. In the second case seen by Bigelow, " the phenomena are 
much like those just described." 

Dr. Bigelow regards them both as subluxations, and speaking of the 
first case, he says the limb " exhibits slight flexion, shortening, and in- 
version. The case seen by Prof. Moore, and of which Prof. Moore ob- 
tained photographs (Figs. 334, 335), is described as follows: John B. 
Parker, private soldier, U. S. V., was skirmishing up a hill. May 13, 
1864, and sprang suddenly back to avoid the gun of a comrade in ad- 
vance. His left foot became entangled, and his weight dislocated the 
hip. He felt the injury, and supposed it out of joint. Some comrades 
put it in, and he immediately resumed his skirmishing, and marched 
seven miles, from 10 A. M. to 6 P. M. He rested at night, and went on 
duty the next day, sharpshooting and crawling all day. He continued 
this kind of duty nine days, and subsequently was on duty in other ways, 
and did not enter a hospital until the fifteenth day after the accident. 
When the case was reported to Dr. Bigelow, the man could luxate the 
hip at any time by pressing the foot on the floor, to fix it firmly, con- 
tracting the adductors, and throwing out the pelvis, when the head " sud- 
denly leaves the acetabulum, and goes on the dorsum." There is a 
slight inversion while the limb remains in this position. Dr. Bigelow 
thinks that this is also a subluxation. 4 

The following case was reported to me in 1865, by John M. Forrest, 

1 Brindley, Sir Ast. Cooper on Disloc. and Frac. Preface to 2d Lond. ed., 1823. 

2 Samuel Cooper, First Lines. New York ed., 1844, vol. ii. p. 385. 

3 (xibson's Surgery, 6th ed., An. 1841, vol. i. p. 387. 

4 Moore, Bigelow, Disloc. and Fractures of the Hip, by Henry J. Bigelow, 1869, 
p. 112. 



806 



DISLOCATIONS OF THE THIGH 



M.D., of Portland, Maine, to whom the man presented himself as a 
" substitute," while Dr. Forrest was in the service of the U. S. Army. 
The application was rejected: — 

"William G. .Gliddon, yet. 37, farmer, says that he has been able to 
dislocate and replace the femur at the left hip-joint since he was a boy. 
It is not the result of any injury or disease, so far as he knows. He is 
in good health, and his muscular development is complete. He accom- 
plishes the dislocation by throwing the weight of his body upon the left 



Fig. 334. 



Fig. 335. 





Voluntary subluxation upon the dorsum ilii. Case of Parker. (From Bigelow aud Moore.) 

leg, and then contracting certain muscles about the hip. The reduction 
is generally more difficult than the dislocation, sometimes requiring the 
aid of his hand. When the head of the bone is out, there is a marked 
projection above and behind the trochanter major, apparently caused by 
the pressure of the head in this situation ; the limb is very slightly if 
at all everted ; while out of place it causes pain ; and after a few repe- 
titions the pain becomes so great as to compel him to desist. The limb 
was not measured while it was dislocated. When the limb is in position 
he does not walk lame." 

The following case came under my personal observation : Dr. William 
G. S., aet. 24, received an injury on the outside of the right knee, in 
February, 1862, from the kick of a horse. There was no apparent in- 
jury of the hip. On the fourteenth day after the accident he rode forty 
miles on horseback, which was followed by some stiffness in the right 
hip. Two weeks later, in mounting his horse, he felt something slip in 
the hip-joint. From that day until this, a period of four years, he has 



VOLUNTARY DISLOCATIONS OF THE FEMUR. 807 

been able to reproduce the same slipping voluntarily, and which phe- 
nomenon I recognize as a dislocation upwards and backwards. I have 
examined him more than once, and he has dislocated and reduced the 
dislocation in my presence repeatedly. Planting his right foot firmly 
upon the floor a little in advance of the left, with his toes turned out, he 
throws his weight upon the right leg by carrying his pelvis well over to 
the right, and then contracts powerfully the gluteal muscles. Instantly 
the head leaves the socket, and seems to mount upon the dorsum ; the 
trochanter major becomes rotated inwards, causing a slight inward rota- 
tion of the leg and foot. He can do the same when lying on his back, 
but not with the same ease. Reduction is accomplished without change 
of position, but by what precise manoeuvre I have not determined. The 
reduction is more quiet, and less sudden, apparently, than the dislocation. 
Both manoeuvres are accompanied with some pain. He is not lame, nor 
does the dislocation take place without his volition. I have seen one 
case, also, which, although pathological in character, was nevertheless 
caused by an early injury, and as such may properly be noticed in this 
connection. 

Dr. 0. Gillett, set. 65 (1867), of Westernville, Oneida Co., N. Y., was 
injured in his left hip-joint when 16 years old, by lifting a heavy 
weight. He felt at the moment something give w T ay in the joint, and 
he has been lame ever since ; at first he was quite lame, but after a 
time the soreness about the joint diminished, and up to within about 
three years the lameness was chiefly due to a lack of development in 
#ie limb. Since then the joint has again become tender, and during 
the last nine months he has been able to throw the head of the bone 
out of the socket, backwards and upwards. Indeed, the bone is dis- 
located whenever he sits down, and resumes its place again when he 
stands up. It is quite apparent that the upper and outer margin of 
the acetabulum is partly absorbed ; and probably, also, the head and 
neck of the femur are in some measure deformed and absorbed. The 
dislocation is apparently incomplete ; and while it exists the thigh is 
abducted and slightly rotated outwards. This abduction and outward 
rotation does not properly belong to a dislocation upon the dorsum of 
the ilium ; but as the condition of the joint and of the adjacent muscles 
is abnormal, it will not require to be explained. 

In some respects the most remarkable example which has come to my 
knowledge, is that of Charles H. Warren, the celebrated contortionist 
and acrobat. Having myself made a careful personal examination of the 
man, and having observed that he does actually subluxate other limbs 
than- the thigh, it has seemed to me that it would throw light upon this 
somewhat obscure class of cases if I were to give his history briefly, and 
describe in detail all the phenomena observed by me. My examination 
of him was made in 1879, when he was thirty-one years old. 

Mr. Warren was born in Schuyler County, New York, in 1848. His 
parents were healthy, and neither of the parents nor either of their five 
jchildren, except Charles, possessed his peculiar muscular development or 
power of dislocating the bones. In his own case it was first noticed in 
his infancy, soon after he began to run about, that he would suddenly fall 
while running across the floor ; and it was soon ascertained that he had 



808 DISLOCATIONS OF THE THIGH. 

been tripped up by the sudden displacement of his hip-joint, but the fall 
would restore it to place and he would get up and again run about. This 
is his own account of his case at this early period of life, and it may or 
may not be correct, as I am not informed that any medical man was ever 
consulted. His statement, however, finds a confirmation in the fact that 
an infant son of Mr. Warren, now dead, had the same peculiarity. He 
has also a little daughter, now living, in whom the same phenomenon, so 
far as the accidental dislocation of the hip-joint is concerned, is mani- 
fested. He has had no other children, and his wife is a healthy and 
well-formed woman. In his own case this tendency to accidental and 
involuntary dislocation of the hip-joint only lasted two or three years after 
he began to run about. Since then it only occurs by an act of volition, 
and under the powerful contraction of the muscles. It is not even apt 
to occur during his performance of gymnastic and contortion feats. 

As a boy, Warren ran about as other children and at five years went 
to school, but when eight years of age he left home and joined a travel- 
ling circus. At eighteen he began to work at the trade of car making, 
but soon returned to the circus. 

I have called attention to these historical details, because they seem 
to illustrate — first, that Warren had a congenital relaxation of the liga- 
ments and capsules of the joints ; and second, that his prodigious mus- 
cular development was the result of early and long-continued muscular 
exercise ; while the daily practice of contortion maintained the ligaments 
and capsules in their original abnormal condition. There is, therefore, 
in this case a combination of anatomical conditions rarely met with, 
namely: a relaxation of one class of structures or tissues, and an unusual 
power of action and contraction in another. We often see persons who 
have congenital or acquired (pathological) relaxation of the articular 
ligaments, but this is associated in most cases with muscular weakness. 
So also there are frequent examples of great muscular power, the result 
of exercise, but the joints are compact also. None of them have the 
power of dislocating their bones by muscular action. Mr. Warren in- 
forms me that Walter Wentworth, a professional contortionist, now about 
forty -five years of age, and weighing perhaps 115 lbs., is probably more 
flexible than himself, but possesses rather less muscular power, yet he is 
very strong. John Santiago de Gibinois and George Mankin are pro- 
bably as strong as himself; Lister, of the New York circus, now dead, 
was probably superior to any one who has ever lived as a contortionist. 
The latter died only two or three years ago, at the age of forty-eight, 
and practised successfully his profession to the last days of his life. 
Yet not one of these men had the power of dislocating his bones which 
Warren possesses. It is clear, therefore, that we must ascribe Warren's 
peculiar power in this respect to a congenital abnormity, namely, a 
great capacity and lengthening of the capsular structures, united with 
later muscular development from exercise. 

Warren is rather above the average height, slender, and well propor- 
tioned. 

Inferior Maxilla ; Partial Dislocation Fonvards. — This is accom- 
plished probably by the action of the external pterygoid muscles. There 
is nothing worthy of special note in this, inasmuch as the ability to dis- 



VOLUNTARY DISLOCATIONS OF THE FEMUR. 809 

place the condyle to this extent is not very unusual. The condyle re- 
sumes its place the moment the action of the muscles ceases. 

Clavicle ; No Displacement. — He has no power to displace the clavicle 
at either articulation. 

Scapula; Displacement of Lower Angle. — This displacement is very 
remarkable, the lower angle of the scapula being lifted upwards and 
outwards until it lies nearly on a level with the top of the shoulder, and 
is made to project far backwards. We are enabled here to study care- 
fully the mechanism of this displacement, an example of which is every 
now and then reported in the journals as a "dislocation" of the scapula. 
It has been ascribed variously to a partial paralysis of the latissimus 
dorsi, in consequence of which the somewhat feeble hold which it has 
upon the inferior angle of the scapula is relaxed, and it is unable to re- 
tain the angle in its place; — to a detachment of this muscle from the 
angle in consequence of some violence; — to paralysis of the serratus 
major anticus ; — and by one writer, to paralysis of the rhomboid mus- 
cles. 

In the case of Warren, it is apparent that it is accomplished solely by 
the action of the rhomboideus major, which muscle he has the ability to 
call into vigorous activity, while he suspends the action of the rhom- 
boideus minor, the serratus magnus, the latissimus dorsi and other mus- 
cles. We can even trace the fibres of the rhomboideus major as it lies 
in a state of contraction underneath the trapezius. When this muscle 
ceases to contract, the angle falls to its place spontaneously. 

It is probable that as we see it presented occasionally in other persons, 
it is due most often to a paralysis of the serratus major anticus ; possi- 
bly sometimes to a loss of power in the latissimus, and even occasion- 
ally to a disruption of the attachment of the latissimus ; but it is impos- 
sible that it should be due to a paralysis of either of the rhomboids as 
has been suggested. Of course we exclude from consideration, now, all 
those examples of scapular projections which are due to spinal distor- 
tions, and which are purely mechanical, and have therefore nothing in 
common with this case. 

Head of the Humerus; Subglenoid Subluxation. — By the action, 
apparently, of the latissimus dorsi, aided, perhaps, by the lower fibres 
of the pectoralis major, Warren displaces the head of the humerus down- 
wards, until it rests upon the lower margin of the glenoid cavity, causing 
a very marked depression under the acromion process, and increasing the 
length of the arm, as measured from this process, about one inch. He 
soon becomes weary of holding it in this position, and then when he re- 
laxes the muscles, the head rises to its socket without noise or sensation. 
His ability to perform this feat, is equal in the two arms. 

Elbow-joint. — The elbow-joint admits of a slight increase of lateral 
motion, above what is usual, and the backward movement, or extension, 
is greater than is usual with adults ; but he has no power to cause either 
a luxation or subluxation at this joint. 

Wrist-joint; Backward, Forward, and Lateral Subluxation. — By 
the action of the muscles alone he displaces the carpal bones backwards 
or forwards, causing in each case a partial luxation. He cannot, how- 
ever, cause a lateral luxation without first grasping the wrist with the 
52 



810 DISLOCATIONS OF THE THIGH. • 

opposite hand — the wrist being grasped firmly by its radial and ulnar 
margins — when, by the action of the muscles, the carpus is thrown fully 
half an inch to either side. When the carpus is thrown to the radial 
side, the hand falls to the ulnar side ; and the reverse happens when the 
carpus is thrown to the ulnar side. When the muscles are relaxed, the 
carpus resumes its position spontaneously, and without sound or sensa- 
tion. 

Phalangeal Articulations ; Subluxations. — He is able to subluxate all 
the articulations of his fingers, including the thumb. The subluxations 
backwards and forwards are effected by muscular action, but the lateral 
luxation only by the help of the other hand. 

Hip ; Apparently Complete Luxation upon the Dorsum Ilii. — It is 
in the hip that the greatest scientific and surgical interest of this case 
centres. After a careful study of the phenomena accompanying certain 
motions of the hip-joint in the person of Warren, I have felt compelled 
to accept of the theory that he causes a true and complete luxation upon 
the dorsum of the ilium. 

We notice that while the patient is standing nude, his form is perfect, 
except that both feet turn out a little more than is usual with others. 
With a moderate effort of the muscles the head of the bone seems to 
move in its socket, and to be carried upwards and backwards upon the 
dorsum ilii. The change of position occurs suddenly, and is accompanied 
with a sensation to the hand as of a bone slipping suddenly into its socket 
— a sort of heavy thud. When he has dislocated his right leg, he stands 
upon his left leg, the right being lifted from the floor, the thigh a little 
flexed upon the body, the leg flexed upon the thigh, with the toes turned 
a little in. He says, that knowing that it ought to turn in a little more 
to represent the appearance which the limb usually presents in this dis- 
location, he sometimes when exhibiting himself, turns it in more ; but this 
is the position, only slightly turned in, which it naturally takes. Look- 
ing for the trochanter major, we find that it has been carried upwards 
and backwards full two inches. The head of the bone we are unable to 
find. It is very difficult to make a comparative measurement of the two 
limbs when one is thus displaced, but so far as I can determine, the right 
limb is shortened at least one inch, probably more. 

Warren repeated the dislocation several times ; the bone always re- 
turning quietly to its place after each displacement, without any sound 
or sensation like that which accompanied its displacement. The same 
experiment was made with the opposite thigh, and with the same results. 
Finally, he was laid upon the floor, upon a blanket, and he produced the 
dislocations equally, but apparently with little more muscular effort. 

There seems to be but two possible explanations of the phenomena 
presented in the case of the femur: either they are produced by the 
trochanter rotating outwards, and pressing firmly against the anterior 
margin of the gluteus maximus, until suddenly it becomes disengaged 
and slips under this muscle, while the head of the bone remains in its 
socket ; or, there is a veritable dislocation of the head of the bone. 

In favor of the first supposition it may be stated again, that when the 
displacement in the case of Mr. Warren has occurred, the trochanter 



VOLUNTARY DISLOCATIONS OF THE FEMUR. 811 

major is removed backwards and upwards full two inches ; it remains as 
prominent as it was before, and the head cannot be found; while in the 
usual dislocation upon the dorsum the trochanter turns forwards, and is 
less prominent than it was before ; and the head of the bone may usually 
be felt when there is no swelling. How then could this be a dislocation? 
Plainly only by supposing that there was such an abnormity of the joint 
— an almost total absence of the rim of the acetabulum in that direction — 
and perhaps such a broadening of the head, and shortening of the neck, 
as would permit the head, neck, and trochanter to be drawn up and back 
by the gluteal muscles, without changing the relations of the line of their 
common axis to the outer face of the pelvis ; that is, without any in- 
ward tilting of the trochanter. This would assume the existence of 
anatomical conditions that are not proven, but only deemed possible. 

If the limb is actually shortened, however, there must be a dislocation, 
and I think it is ; but inasmuch as the accuracy of any measurements 
under these circumstances might be fairly questioned, we shall for the 
moment dismiss this argument also. 

There now remains only this important fact, that while the trochanter 
major is carried back, the toes are no longer very much turned outwards, 
as they were before the displacement was made ; nor do they point for- 
wards, but actually a little inwards. So that in fact there is about as 
much inward rotation of the foot as we could have required to indicate 
an outward dislocation. But it is plainly impossible that the head of 
the femur should remain in its socket, while the trochanter is rotated 
outwards two inches, and the knee, foot, and toes not accompany this 
outward rotation. Certainly it is impossible that the whole lower portion 
of the limb should rotate inwards, as it actually does, while the tro- 
chanter is strongly rotated outwards. These considerations, it seems 
to me, must exclude the supposition that there is here only a rotation of 
the trochanter outwards, and a consequent muscular displacement. 

Whatever difficulties there may be in the way of supposing that this 
is a dislocation, they are not insuperable if we assume the existence of 
some abnormity in the construction of the joint and of the neck. It 
is possible even, that what we believe to be the trochanter moved back 
is actually the head of the bone, and that it is the trochanter which is 
lost; for the change of position occurs so suddenly that neither by the 
sight, nor with the hands placed upon the trochanter can we follow the 
change of position. I only discover, after a sudden commotion, that 
there is no longer a projection where the trochanter was felt, and which 
I marked with a pencil in order not to be deceived ; and that there is a 
projection which resembles it precisely, so far as we can determine, two 
inches farther back and upwards. Possibly, I say, this new projection 
is really the head, somewhat changed from its normal form ; but I do not 
think so. Perhaps nothing but an autopsy can determine this and other 
points connected with the case. 

Knee-joint ; Rotation and Subluxation. — Mr. Warren has no power 
to displace the knee-joint by muscular action ; but seizing the leg while 
it is flexed, he can rotate the tibia laterally very freely, and cause the 
head of the tibia to project beyond the line of the articulation half an 
inch or more. 



812 



DISLOCATIONS OF THE PATELLA. 



Patella. — He has no power to displace this bone. 

Ankle-joint.— With his hands he can abduct and adduct this joint 
almost to a right angle with the leg. 

Tarsal Joints. — By the aid of his hands he can imitate the extremes 
of varus and valgus. 

Phalanges of the Toes. — They are loose, but not so loose in their 
articulations as the phalanges of the fingers. 



CHAPTEE XVII. 



DISLOCATIONS OF THE PATELLA, 



Fig. 336. 



§ 1. Dislocations of the Patella Outwards. 

Causes. — In the majority of cases this dislocation has been occasioned 
by muscular action ; and especially is this liable to occur in persons who 
are knock-kneed, or whose external condyles have not the usual promi- 
nence anteriorly. It may be caused by suddenly twisting the thigh 
inwards while the weight of the body rests upon the foot, and the leg is 
thus kept turned outwards ; or by falling with the knee turned inwards 
and the foot outwards. Occasionally it is the result of a blow received 
upon the inside, or upon the front and inner margin of the patella. In 
some persons there seems to exist a preternatural laxity of the liga- 
mentum patellae or of the tendon of the quadriceps extensor, which 
exposes the subject to this accident from very trifling causes. Fergus- 
son says he has known it to be occasioned by a child's 
stepping upon the knee of a person lying in bed; and 
Skey says he has seen two cases which occurred spon- 
taneously during sleep. B. Cooper has seen a young 
lady who frequently dislocated her patella outwards 
by merely striking her toe against the carpet, or in 
dancing. Boyer, Sir Astley Cooper, and others men- 
tion similar examples. 

Pathological Anatomy. — Most frequently the dis- 
location is only partial, the inner half of the patella 
resting upon the articular surface of the outer con- 
dyle ; and in consequence of the peculiar obliquity of 
these surfaces, together with the action of the vasti 
and rectus femoris, the outer margin of the patella 
becomes tilted forwards. 

If the dislocation is more complete, this margin 
begins to fall over backwards, as in the accompany- 
ing drawing ; and in more extreme cases the patella 
lies flat upon the outer side of the condyle, with its 
inner margin directed forwards. 

When the dislocation is partial, it is probable that 
neither the capsule nor the ligamentum patella? usually suffers much 




Dislocation of the pa 
tella outwards. 



DISLOCATIONS OF THE PATELLA OUTWARDS. 813 

laceration ; but in complete dislocations the capsule at least must have 
given way more or less. Norris, of Philadelphia, reports a case of 
partial luxation in which the complications were more serious. John 
Scanlin, set. 32, was admitted to the Pennsylvania Hospital, on the 27th 
of August, 1839, in consequence of injuries received a short time pre- 
vious by having become entangled in machinery. In addition to several 
fractures in other limbs, he was found to have a subluxation of his left 
patella outwards, its outer edge being much raised, and resting on the 
side of the external condyle of the femur, while its inner edge was de- 
pressed, and firmly fixed in the hollow between the condyles. The in- 
ternal lateral ligament of the knee was ruptured, allowing the head of 
the tibia to be moved considerably outwards. A depression existed, 
also, between the tubercle of the tibia and the lower end of the patella, 
at the middle and inner side of the knee, evidently produced by a rup- 
ture of the ligamentum patellae in nearly its whole extent. There was 
almost no swelling, and the limb was moderately flexed. By firm pres- 
sure the patella could be restored to position, but as soon as the hand 
was removed it returned to its original position. At the end of two 
months " a good degree of motion existed at the knee-joint, which was 
in no way inflamed or painful." 1 

Symptoms. — The limb is slightly bent, but immovable ; the breadth 
of the knee is considerably increased ; the inner condyle projects un- 
naturally, and the patella is distinctly felt upon the outer side. If the 
dislocation is partial, the outer margin of the patella forms an irregular 
sharp ridge in front of the external condyle. If it is complete, the 
inner margin presents itself in front of the external condyle, and the 
outer margin looks backwards. Usually the patient suffers great pain 
as long as the dislocation remains unreduced. 

Watson, of New York, saw a case of complete dislocation of the 
patella outwards in a fat young lady with lax fibre, and occasioned by 
dancing. He says the knee was slightly but firmly flexed. It was re- 
duced by very slight pressure Avith the fingers, and although some in- 
flammation with effusion into the joint ensued, the use of the limb was 
completely restored in a week or ten days. 2 

Prognosis. — Reduction is in general easily accomplished, but a relux- 
ation is very prone to occur. In a few examples reported of a perma- 
nent luxation, the patients have eventually recovered the use of the limb 
in a great measure. Boyer saw four cases of this kind, in three of which it 
existed in the left leg, and had remained from infancy. The patellae were 
easily replaced, but unless confined they soon became displaced again ; 
not one of them found it necessary to apply for surgical aid, as " they 
suffered no great inconvenience from the luxation, and it exempted them 
from military service." 

After reduction very little or no inflammation usually follows. Mr. 
Key has, however, narrated a case in Guy's Hospital Reports, of death 
from suppuration in the knee-joint, following upon the reduction of an 
inward subluxation. The dislocation was produced by a fall while car- 

1 Norris, Amer. Journ. Med. Sci., vol. xxv., Feb. 1840, p. 276. 

2 Watson, New York Journ. Med., vol. i. p. 306. 



814 DISLOCATIONS OF THE PATELLA. 

Tying a pail, and was reduced by very gentle pressure ; but the patient, 
a girl set. 20, although apparently in good health, was believed to be 
somewhat strumous. 1 

Treatment. — In order to relax completely the quadriceps extensor, by 
whose action chiefly the patella is held in its unnatural position, the body 
should be bent forwards, while at the same moment the leg is extended 
upon the thigh and the thigh flexed upon the body. The surgeon will 
accomplish these indications in the most simple manner by placing the 
patient in a chair and then lifting the foot upon his own shoulder, as he 
kneels or sits before him. Sometimes the patella will resume its position 
at once when this manoeuvre is adopted ; but if it does not, slight lateral 
pressure, made with the fingers, will generally be found sufficient to 
accomplish the reduction. 

A man, set. 27, was sitting on a box, and in jumping off tripped him- 
self with his right leg, causing a partial dislocation of the patella of the 
left leg outwards. Half an hour after the receipt of the injury I found 
him sitting with the knee bent, and in great pain. The patella lay upon 
the outer half of the articular surface, with its outer margin a little tilted 
upwards. Lifting the leg and thigh to a right angle with the body, and 
making very slight pressure upon the outer margin of the patella, it im- 
mediately resumed its place. Yery little inflammation ensued. 

In some instances, where other means have failed, the reduction has 
been effected by violent flexion and extension of the knee, aided by 
lateral pressure. 

I have already mentioned, when speaking of dislocation into the fora- 
men thyroideum, the case of N. Smith, in whose person I found at the 
same moment a dislocation of the thigh, a subluxation outwards of the 
tibia, and a complete outward luxation of the corresponding patella. 
This was occasioned by a fall from a height upon the inside of the knee. 
I reduced the tibia first, and then easily replaced the patella by lifting 
the leg and pushing with my fingers against its outer margin. 

In many cases the patients themselves have reduced the dislocation 
immediately, and the surgeon is only consulted in relation to the after- 
treatment. Liston says that this is so constantly the fact, or else such 
dislocations are really so rare, that it has never happened to him to have 
an opportunity of reducing any form of dislocation of the patella. 

A young gentleman, set. 25, residing in Somerset, N. Y., called upon 
me in consequence of having discovered a floating cartilage in his knee- 
joint. His account of the matter was that on the 1st of February, 1858, 
he was kicked by a cow upon the outside of the right leg, about six 
inches below the knee, and that he immediately found the patella dislo- 
cated outwards. After several efforts, he finally succeeded in reducing 
it himself. His knee soon became greatly swollen, so that for five weeks 
he was unable to walk, and he has been more or less lame to this time. 
Six months after the accident he discovered a floating cartilage on the 
inside of the patella, about one inch in diameter, which occasionally slips 
between the joint surfaces, and suddenly trips him up. 

' Op. cit., vol. i. p. 260. 






DISLOCATIONS OF THE PATELLA UPON ITS AXIS. 815 



Fig. 337. 



§ 2. Dislocations of the Patella Inwards. 

Causes. — Less frequent than dislocations outwards, they are occasioned 
generally by direct blows received upon the outer mar- 
gin of the patella. 

The symptoms, pathological anatomy, and treatment, 
will be the same as in dislocations outwards, except 
so far as these must necessarily vary from the opposite 
position of the patella. 

§ 3. Dislocations of the Patella upon its Axis. 



Syn. — " Semi-rotation ;" Miller. 
gaigne. 



Luxation Verticale ;" Mai- 




Dislocation of the 
patella inwards. 



These accidents, of which I have found recorded 
about twenty-four examples — and one additional case 
has been seen by myself — seem to be the result of the 
same causes which produce lateral luxations ; and, in- 
deed, they may be regarded as only exaggerated forms 
of incomplete lateral dislocations. In these latter ac- 
cidents, as we have already noticed, the external or the 
internal margin of the patella, according as the sub- 
luxation is to the outer or inner side, is thrown more 
or less obliquely forwards ; a position into which it is carried partly by 
the peculiar form of the articulating surfaces, and partly by the action 
of the vasti and rectus femoris muscles. If now these muscles were to 
contract suddenly and violently, and the return of the patella to its nor- 
mal position were prevented by the lodgment of one of its margins in the 
intercondyloidean fossa, the other or free margin would be compelled to 
rise until it became perpendicular to the limb, or it might perhaps even 
become completely reversed in its socket. 

The signs of the accident are such as to render an error in the diag- 
nosis almost impossible. The limb is generally found forcibly extended, 
occasionally it is in a position of moderate flexion, but the projection of 
the sharp border of the patella directly forwards under the skin is itself 
sufficient to determine the true nature of the injury. 

Reduction may be effected by the same manoeuvres which we have 
recommended in lateral luxations ; but if these measures do not succeed, 
we may direct the patient to make a violent effort himself to flex and 
extend the limb, or the surgeon may force the limb into flexion and 
extension alternately, or he may rotate the tibia upon the femur, and 
then flex. Finally, he ought to make use of lateral pressure also, upon 
both margins of the upright patella, but in opposite directions. 

In all cases it would be advisable to put the patient under the influence 
of an anaesthetic before attempting reduction. In a case reported by 
Dr. H. Hunt, of Beloit, the reduction occurred spontaneously as soon as 
the patient was chloroformed, although it had resisted all the efforts 
previously made. 1 



1 H. Hunt, M.D., the Medical Record, April 1, 1873. 



816 DISLOCATIONS OF THE PATELLA. 

Watson, of New York, has related the following example of rotation 
of the patella upon its inner margin (" Luxation Verticale Externe," 
Maty.) :— 

Henry Burton, aged about thirty-five years, of rather slender frame, 
while riding on horseback in a crowd, received a blow upon his knee 
from a horse ridden by another person. When seen by Dr. Watson, 
soon after the accident, .the leg was perfectly straight, but could be 
flexed to about an angle of 140° without causing pain. " The patella 
appeared to be slightly drawn up, and it was twisted upon its axis, pre- 
senting its outer edge, in a prominent hard line, in front of the knee ; 
its inner edge was resting either in the groove between the condyles of 
the femur, upon which its posterior face should naturally play, or in the 
small depression on the anterior face of the femur, immediately above 
this groove. The anterior surface of the patella was turned inwards, its 
posterior surface outwards, and it rested nearly at right angles with its 
natural position. Its upper and lower attachments were both preserved, 
and could be distinctly felt ; and a sort of band appeared to pass from 
its under, or, as it now lay, its outer face, inwards to the deeper portion 
of the knee-joint. This band, as I conceived, was caused either by the 
tension of the capsular ligament, or by the rupture of its edge, as it 
passes from the outer side of the patella. The position of the bone 
was so well marked that no one at all acquainted with the anatomy of 
the part could mistake the nature of the accident. 

" With the leg extended, and the anterior muscles of the thigh forced 
downwards as much as possible, pressure was made upon the patella, 
with the expectation of forcing down its prominent edge. The effort 
was followed only by an increase of pain, the bone remaining perma- 
nently fixed. Another attempt was made to cant its posterior edge 
inwards, and to bring its anterior edge outwards, without pressing against 
the condyles of the femur, by forcing the head of a key against the pos- 
terior, now the outer, face of the patella (using this as a fulcrum), and 
pressing the prominent edge of the bone toward the outer condyle. This 
manoeuvre gave him no pain, but was as fruitless in its result as the 
other. At length the knee was forcibly bent and immediately straight- 
ened again ; and then, by canting the patella as before, and pushing it 
slightly downwards and inwards, it sprung with a sudden snap into its 
proper position." 1 

Dr. Joseph P. Grazzam, of Pittsburg, Pa., has met with a similar case. 
On the 10th of September, 1842, James Porter was thrown while wrest- 
ling, and immediately found himself unable to rise. Dr. Grazzam saw 
him about an hour after the accident, and found the patella of the right 
leg dislocated on its axis, and resting on its inner edge in the groove 
between the condyles of the femur. Dr. G. proceeded to attempt reduc- 
tion, but failed, after having made repeated trials by lifting the limb 
toward the body and by pressure in opposite directions. In consultation 
with Dr. Addison, it was now determined to divide the ligamentum 
patellae, which was done by introducing beneath the skin a narrow- 
blacled knife, and cutting close to the tubercle of the tibia. Again the 

i Watson, New York Journ. Med., Oct. 1839, p. 302. 






DISLOCATIONS OF THE PATELLA UPON ITS AXIS. 817 

attempts at reduction were renewed, but without success. The patella 
could be moved on its edge more freely than before the cutting, but 
resisted every effort to replace it. The patient was now bled in the 
erect posture and until the approach of syncope, but to no purpose. On 
the following morning it was determined to adopt, with some modifica- 
tion, the mode practised so successfully by Dr. Watson. " The thigh 
was strongly flexed," says Dr. Gazzam, " on the pelvis, and the heel 
elevated. Then the leg was flexed steadily and forcibly on the thigh, 
and suddenly straightened. At the moment of straightening the leg, I 
pressed very strongly against the lower edge of the patella from without, 
with the head of a door-key well wrapped, while Dr. Addison pressed 
with both thumbs against the upper edge of the bone toward the external 
condyle. On the fourth trial this manoeuvre succeeded, the bone spring- 
ing into its place with a snap." Recovery was uninterrupted, and two 
or three months after, the patient had the complete use of his limb. 1 

The following case is reported by Dr. S. F. Morris, New York: — 

" Mr. B., aged 27, of slender build, while playing at ball, in endea- 
voring to strike the ball had to jump up and turn partially round, when, 
on resuming his former position, he fell, his leg refusing to bend. He 
appreciated the nature of his injury, and, with the aid of the men in the 
store, endeavored to ' push it back.' Failing in this, surgical aid was 
sought, but, despite three attempts at reduction, the patella remained 
displaced. He was then taken to his home. 

" I saw him about two hours after the accident. He complained of 
severe pain when any manipulation was made. The leg was perfectly 
straight. The patella was firmly wedged (its outer edge) in the inter- 
condyloid fossa ; its anterior surface looking outwards and slightly down- 
wards, its posterior face looking inwards and upwards. The prominence 
of the edge of the patella, thus twisting on its longitudinal axis, left no 
doubt as to the diagnosis. 

"No attempt was made at reduction by me until the patient was ether- 
ized, when, assisted by Dr. C. M. Bell, of this city, it was easily per- 
formed in the following manner: The leg was raised from the bed, the 
thigh flexed on the pelvis. Dr. Bell then placed his thumb, as a fulcrum, 
beneath the under (posterior) surface of the patella, and pressed on the 
upper (anterior) surface ; at the same time I slightly flexed, then suddenly 
extended and rotated the leg inwards. The patella immediately resumed 
its natural position." 2 

Dr. Sternberg, Assistant Surgeon U. S. A., has also published a case 
in the Medical and Surgical Reporter, reduced readily when the patient 
was under the influence of chloroform. I am unable to find the date of 
the record, but I think it was in 1869. 

The following case is reported by G. P. Davis, M.D., of Hartford, 
Conn. 

U A few weeks ago I was summoned to a nurse girl, who was reported 
to have 'put her knee out of joint.' On entering the room, I found the 

1 Gazzam, Araer. Journ. Med. Sci., vol. xxxi., April, 1843, p. 363. 

2 Morris, New York Med. Record, May 15, 1869. 



818 DISLOCATIONS OF THE PATELLA. 

patient lying on her face, both legs extended, and the left foot pointing 
towards its fellow. 

" On turning the patient upon her back, the left patella was plainly 
seen in a condition of 'vertical' displacement, i. e., turned upon its inner 
edge, so that its upper surface looked toward the opposite knee. It was 
rigidly fixed, and the limb was entirely helpless. 

" I learned that while sitting upon the floor, playing with the baby 
under her charge, she suddenly reached forward, at the same time twist- 
ing her body partly around, in order to seize the child, who was a little 
out of her reach, and who, she feared, was about to fall. She immedi- 
ately became conscious that an accident had befallen her knee. 

" The patient was etherized as she lay upon the floor. The whole limb 
was then elevated by an assistant, so as to relax the muscles in front of 
the thigh, and, by forcibly crowding down these muscles toward the knee 
with one hand, manipulating the patella at the same time with the other, 
reduction was effected with the utmost ease." 1 

April 1, 1875, through the courtesy of Dr. A. R. Robinson and of 
Prof. S. B.Ward, of New York, I was permitted to see a case of u semi- 
rotation" of the patella. The accident had happened the day before, in 
the person of Susan Newman, aet. 31, a muscular Scotch woman, while 
wrestling. Dr. Robinson being called, attempted reduction by pressure 
and by other means, but without success. About seventeen hours after 
the accident I found her in bed with the left leg extended upon the thigh, 
and the patella standing upon its inner margin, which rested in the in- 
tercondyloid notch. The patella was not vertical, but leaned over toward 
the outside of the knee. 

While placing her under the influence of chloroform, she bent her leg 
to a right angle, but the patella continued to occupy its abnormal posi- 
tion. When completely under its influence, Dr. Ward extended and 
flexed the leg with no result. He then tilted the patella down until it 
lay flat upon the outer condyle (this was the position it took also when, 
being partially chloroformed, she flexed the leg); and after a second at- 
tempt, with moderate pressure against the outer margin of the patella, 
it suddenly resumed its position. None of the tendinous or muscular 
attachments were ruptured. 

Dr. J. M. Boyd, of Thorntown, Indiana, reports a case of vertical 
dislocation, the patella resting upon its internal margin, in a negro 38 
years old, and which was caused by muscular " spasms." Attempts 
were immediately made by a surgeon to reduce it, but without success. 
Subsequently Dr. Boyd tried also and failed ; but at the end of two weeks 
the muscular spasms returned, and before Dr. Boyd could reach the house 
the bone had resumed its position spontaneously. 2 Malgaigne has re- 
ported, also, a case in the Gazette Medicate, for 1836, in which reduc- 
tion was accomplished spontaneously during an attempt made by the 
patient to walk. The same writer refers to a case reduced under the 
influence of chloroform. Mr. Flower {Holmes's Surgery) records a 
similar case. 

1 Davis, Med, Record, Dec. 1, 1874. 

* Boyd, Western Journ. Med., May, 1868, p. 275, and June, 1868, p. 341. 



DISLOCATIONS OF THE PATELLA UPWARDS. 819 

In a case of the same kind, published originally in Rustfs Magazine, 
and which is copied at length by Mr. B. Cooper in his edition of Sir 
Astley's great work, the reduction was found impossible, notwithstanding 
the surgeon finally had the temerity to sever completely the tendon of the 
quadriceps extensor, and the ligamentum patellae. Extensive suppura- 
tion followed, under which the poor fellow finally sank and died. 

Dr. Alexander N. Dougherty, of Newark, N. J., has reported a case 
in which he succeeded in effecting reduction by pressure made with his 
hand while the limb was in an extended position, and without anaesthesia. 1 

Dr. Wm. B. Bradner, of Warwick, Orange Co., N. Y., reports a case 
occurring in a boy, set. 9 years, caused by a fall in wrestling. The limb 
— the right — was slightly flexed. Dr. Bradner describes the reduction 
as follows : " To relieve the strain upon the patella preparatory to re- 
duction, I seized his ankle in my right hand, and raised it from the bed ; 
then I placed my left hand over the patella and grasped the knee ; then 
by depressing the knee forcibly with one hand, and raising the heel with 
the other, I found it a very easy matter to rotate the patella to its normal 
bed." The boy recovered at once the complete use of his limb. 2 

Dr. W. R. Cluness, of Sacramento, Cal., reports a case reduced by 
him in the extended position and by lateral pressure. 3 

In a case occurring in a lady, 36 years of age, solely from muscular 
action, the reduction was easily effected by Blair D. Taylor, Assistant 
Surgeon U. S. A., by bending the knee as much as possible, and then 
suddenly straightening it, while at the same moment the patella was 
pressed firmly over. 4 

§ 4. Dislocations of the Patella Upwards. 

Occasionally the ligamentum patella has been found so much elongated 
and relaxed, as to permit the patella to glide upwards upon the front of 
the femur. Heister and Ravaton have each seen an example in which 
a displacement from this cause existed to the extent of three inches. It 
is much more common, however, to meet with this dislocation as a result 
of a rupture of the ligamentum patellae, as the following example will 
illustrate. 

On the 18th of Dec. 1850, Dennis Milliards, set. 50, was admitted 
to the surgical wards of the Buffalo Hospital of the Sisters of Charity. 
While at work on this same day, he had slipped and fallen, with his 
knee forcibly flexed under his body. I found the ligament of the 
patella torn asunder, and the patella draw T n up two or three inches upon 
the front of the thigh. We applied at once the dressings used by me 
for a broken patella, and were able to bring the bone down completely 
to its place. Three weeks from the time of the receipt of the injury the 
dressings were removed, and the patella was found to be nearly but not 
quite in its original place. From this time we commenced to move the 

1 Dougherty, Med. Record, Dec. 30, 1876, p. 340. 

2 Bradner, Ibid., Jan. 20, 1877, p. 46. 
8 Cluness, Ibid., Jan. 27, 1877. 

4 Taylor, Ibid., May 26, 1877, p. 336. 



820 DISLOCATIONS OF THE HEAD OF THE TIBIA. 

joint : in about ten days more he left the hospital, and I lost sight of 
him, so that I am unable to speak more definitely of the result. 

In February, 1869, Dr. George H. Smith consulted me in relation to 
a gentleman who had ruptured the ligament of the patella in both legs, 
a little more than a year before, by catching his heel in descending 
from a carriage ; the ligaments giving way in the powerful muscular 
effort which he made to prevent himself from falling. 

Treated upon a single inclined plane in the same manner that I have 
recommended for a fractured patella, at the end of five weeks the pa- 
tellar were in place and the ligaments reunited. After walking about 
one month upon crutches he caught the heel of his right foot again and 
again ruptured the ligament of the patella in the same leg. A similar 
plan of treatment failed to accomplish anything, and when he consulted 
me the patella was displaced three inches upwards. He could raise the 
leg slowly to a position of extension while sitting, and was able to walk 
four or five miles a day. 

Gibson has recorded a similar case, in which both patellae were dis- 
located upwards by a rupture of the ligaments, occasioned by the 
exercise of leaping. He recovered the use of his limbs almost com- 
pletely. 1 



(For examples of rupture of the quadriceps femoris, which some 
writers have incorrectly named Dislocations of the Patella Downwards, 
see Velpeau's Surgery, 1st Amer. ed., vol. i. p. 422 ; New York Med. 
Times, April 6, 1861, p. 226, and two cases reported by myself in the 
same volume of the Med. Times.) 



CHAPTER XVIII. 

DISLOCATIONS OF THE HEAD OF THE TIBIA (FEMORO-TIBIAL). 

Syn. — " Tibia upon the femur ;" " dislocations of the leg." 

In consequence of the great size and irregularity of the articular 
surfaces between the tibia and femur, together with the remarkable 
number and strength of the ligaments which bind the two bones together, 
dislocations at this joint are exceedingly rare. They are known to take 
place, however, in four principal directions, namely, backwards, for- 
wards, inwards, and outwards. A dislocation may also occur in either 
of the diagonals between these points, that is, antero-laterally or postero- 
lateral^. They may be either complete or incomplete. Velpeau has 
found upon record thirteen examples of complete dislocations forwards 
and eight backwards, but not one of a complete lateral luxation. Yel- 

1 Gibson, Surgery, vol. i. p. 395, 6th ed. 



DISLOCATIONS OF HEAD OF TIBIA BACKWARDS 



821 



peau thought, also, that the antero-posterior luxations were always com- 
plete, but Malgaigne has shown that this opinion is erroneous. 

Simple flexion and extension, however extreme, are generally insuffi- 
cient to produce either of these dislocations. They may be produced 
by a violent blow upon the lower end of the femur or upon the upper 
end of the tibia, or by twisting the tibia upon the femur, as when the 
foot is made fast in a hole, and the body swings around upon the knee. 



Fig. 338. 



8 1. Dislocations of the Head of the Tibia Backwards. 

Symptoms. — The head of the tibia is felt in the popliteal space ; and, 
if the dislocation is complete, the pressure upon the popliteal nerve be- 
comes excessively painful. 

A marked depression exists in front, immediately below the patella, 
and especially upon the sides of the ligamentum patellae ; the condyles of 
the femur project strongly in front ; the leg may 
be not at all or only slightly shortened, or the 
shortening may amount to one inch or more ; and 
usually it is in a position of extreme extension, or 
thrown forwards from the line of the axis of the 
femur ; but its position has been found to vary 
greatly in different cases, the limb being some- 
times very much flexed, and in others very slightly 
flexed, or perfectly straight. 

Pathological Anatomy. — The posterior liga- 
ment of the joint is torn ; the muscles of the 
ham are put upon the stretch ; the popliteal 
nerves and vessels compressed ; and the head of 
the tibia either rests partly upon the posterior 
half of the lower articulating surface of the 
femur, or it passes up and rests only against its 
posterior articulating surface, which in this 
direction extends an inch or more upwards. If 
the dislocation is complete, the crucial liga- 
ments are also torn, and all the parts about the 
joint suffer extensive injury from stretching, laceration, or compression. 

Prognosis. — Malgaigne has seen three examples of incomplete back- 
ward luxations which were not reduced, and neither of the persons was 
very greatly maimed in consequence. One walked with crutches after 
three or four days, and with a cane after about five weeks. Another 
did not leave his bed under one month, and it was nearly one year 
before he could lay aside his crutches ; but both of them were finally 
able to walk at least twelve leagues per day. Malgaigne informs us, 
however, that in a similar case seen by Lassus, the patient was confined 
to his bed two years, although he finally recovered a tolerable use of his 
limb. 

If the reduction is promptly effected, the limb kept perfectly quiet a 
sufficient length of time, and in other respects properly managed, not 
much inflammation need generally be anticipated, and the limb may 
suffer in the end very little if any maiming. 




Dislocation of the head of the 
tibia backwards. 



822 DISLOCATIONS OF THE HEAD OF THE TIBIA. 

Treatment. — It will be proper, at first, to attempt the reduction by 
simple manipulation, as this is often found to succeed when the disloca- 
tion is recent and incomplete, and especially when the system is greatly 
depressed by the shock of the injury. If the dislocation is complete, 
however, we can hardly anticipate success without the application of 
some extending force. 

In the employment of manipulation we ought to be governed at first 
by the same rule which we have found so generally applicable in dislo- 
cations of the femur, namely, to carry the limb in those directions in 
which it will move easily, or without the application of much force. If 
this fails, we may at once resort to forced flexion alternating with ex- 
tension ; rotating or rocking the limb also occasionally from one side to 
the other, while at the same moment strong pressure is made upon the 
projecting bones at the knee-joint in opposite directions, or in the direction 
of the articulation. 

Finally, it may be necessary to resort to extension, made by means of 
a lacq, or by the hands of strong assistants, above the ankle, always at 
first in the direction of the axis of the tibia ; the counter-extending band 
being applied to the perineum if the leg is straight, but to the lower and 
back part of the thigh if the leg is flexed. 

A very convenient mode of making extension, where we wish to apply 
more than usual force, is to lay the whole limb over a firm double- in- 
clined plane, or fracture splint, securing the thigh to the thigh-piece 
with a roller, and making the extension with the screw attached to the 
foot-board. This method, however, while it enables us to use great 
force in the extension, prevents the surgeon from employing, at the same 
time, those flexions, extensions, and other manipulations, upon which 
success so often depends. 

Dr. James Carmichael has reported a case in which reduction was 
effected easily by flexion, when traction had failed. 1 

Mr. Rose has related, in the Provincial Med. Journal of June 11, 1842, 
a characteristic example of this accident, except that the patella had also 
suffered a lateral displacement, presenting the usual favorable termination. 

A woman was standing upon a low ladder, when a carriage driven 
furiously came in contact with it, and precipitated her to the ground. 
Mr. Rose, who saw her almost immediately, found the tibia completely 
dislocated at the knee, the head being driven behind the condyles of the 
femur into the ham, with the patella thrown to the outside of the ex- 
ternal condyle, and the leg in a state of fixed extension. Immediately, 
and without difficulty, the bones were restored by applying one hand to 
the patella, the other to the back of the upper portion of the tibia, and 
simultaneously pulling and pushing those bones toward their natural 
positions. The patient was then removed to a bed, and by the diligent 
use of antiphlogistic remedies inflammation was kept in check, and the 
case reached a favorable termination without one untoward symptom. 
After the lapse of only a few weeks, she had completely recovered the 
use of the knee-joint. 2 



' New York Med. Gazette, Aug. 22, 1868 ; from the Lancet. 
2 Rose, Am. Journ. Med. Sci., vol. xxxi. p 216. 



DISLOCATIONS OF HEAD OF TIBIA FORWARDS. 



823 



Dr. Walsham communicated a case to Sir Astley Cooper, in which 
the dislocation was not only complete, but the tendon of the quadriceps 
extensor was ruptured. The leg was bent forwards. The reduction 
was accomplished very easily by extension made with the hands by four 
men, in the line of the axis of the limb. In about one month this man 
began to walk with crutches, but he was not perfectly recovered until 
after five months ; at which time the crutches were finally laid aside. 1 



§ 2. Dislocations of the Head of the Tibia Forwards. 

The signs of this accident are the reverse of those which belong to 
dislocations backwards. The patella, tibia, and fibula are prominent in 
front, while the condyles of the femur may be felt behind, pressing 
strongly upon the muscles, nerves, and bloodvessels which occupy the 
popliteal space. In case the dislocation is complete, a shortening may 
exist to the extent of one or even three 
inches. Dr. O'Beirne, of Dublin, has men- FlG - 339 - 

tioned a case to Mr. B. Cooper, in which 
the shortening was three inches and a half, 
and Mr. Mayo has seen one example in 
which the dislocated limb was " fully four 
inches" shorter than the other. 2 

In consequence of the pressure upon the 
popliteal artery, the pulsations in the 
branches below are frequently interrupted, 
and in one instance this pressure was suf- 
ficient to produce finally a dry gangrene. 

Dr. Gorde relates a case in the Bulletin 
de Therapeutique, occurring in a woman 
nearly sixty years old. This woman was 
returning home at night with a heavy bur- 
den, and in a state of intoxication, when she 
stepped into a ditch as deep as up to the 
middle of her thighs. The body was thrown 
forwards by the fall, while the feet stuck at 

the bottom of the ditch ; the whole force of the impulse being sustained 
by the thighs. The lower end of the femur was found driven downwards 
and backwards, and lodged under the muscles of the calf of the leg ; 
the limb being shortened three inches. Reduction was promptly effected, 
and without inflicting any pain of which the patient complained. In six 
weeks the patient was cured. 3 

Mr. Toogood has reported also, in the Provincial Medical Journal of 
June 18th, 1812, an example of complete dislocation in this direction, 
in which the appearance was so dreadful, that Mr. Toogood at first de- 
spaired of being able to reduce it ; but by directing two men to make 
counter-extension while he made extension, the reduction was immedi- 
ately effected. At the end of one month the patient was able to leave 




Incomplete dislocation of the head of 
the tibia forwards. 



1 Walsham, Sir A. Cooper on Disloc, etc., 2d Lond. ed., p. 188. 

2 B. Cooper's ed. of Sir Astley Cooper on Disloc, etc., pp. 214, 215. 

3 Gorde, Am. Journ. Med. Sci., vol. xvi. p. 225, May, 1835. 



824 DISLOCATIONS OF THE HEAD OF THE TIBIA. 

his bed ; and sixteen years after, Dr. Toogood saw him walking "with 
very little lameness." 1 Parker, of Liverpool, has reported another ex- 
ample in the London and Edinburgh Monthly Journal for December, 
1842, which was occasioned by the fall of a heavy spar upon a man's 
back, and the consequent violent bending of the knee under his body. 
In this case the limb was slightly flexed, and the patella was loose 
and floating. The reduction was effected without much difficulty by ex- 
tension and counter-extension made by two men, while the operator, 
placing his knee in the ham of the patient, attempted to bring the leg to 
a right angle with the thigh. 2 

B. Cooper, Malgaigne, Little, 3 and others, have recorded examples of 
this accident. 

March 9, 1865, Hiram Wescott, of Sandy Cove, Nova Scotia, set. 45, 
was caught by his sled, drawn by horses, in such a way that a beam 
pressed against the front and lower end of the femur while the heel was 
caught and arrested by a stump. The foot was thrown forwards and 
the upper end of the tibia completely dislocated in the same direction. 
It was at once reduced by a person who was present, but on attempting 
to use the leg in walking it was reluxated immediately. Mr. J. H. 
Harris, medical student, found the limb soon after completely luxated, 
with the leg thrown forwards in the position of dorsal flexion about 40°. 
The tendons of the hamstring muscles were not ruptured, but had slid 
forwards past the condyles of the femur. There was no external wound. 
Reduction, was easily accomplished by simple extension. Pasteboard 
splints were then applied. On the third day the knee was considerably 
swollen, and some ecchymosis existed about the popliteal region. On 
the fifth day these symptoms had much increased. Mr. Harris then 
applied extension to the foot, with the aid of adhesive plaster, pulley 
and weights, and by elevating the foot of the bed. The amount of ex- 
tension employed was. 9 lbs. This gave immediate relief to the pain, 
and was continued until the inflammation subsided. His recovery was 
steady, and in four months he walked with crutches or a cane. 

In 1864 a similar dislocation was presented at the Brooklyn City Hos- 
pital, in which reduction having been practised, the patient died. The 
case is reported very fully by Dr. Le Roy M. Yale. 4 

Dr. White, of Buffalo, politely invited me to see with him a lad, -set. 
10, whose tibia had been partially dislocated forwards eight weeks 
before, by a boy having hit the top of his knee with his head, while 
they were at play. His father, who is himself a physician, residing 
near town, reduced the limb very easily, by extension made with his 
own hands, and by pressing upon the projecting bones. Violent inflam- 
mation ensued, but at the time when I saw him, the knee was free from 
soreness or swelling, and the motions of the joint were nearly restored. 

Dr. Charles S. Downes, of Mclndoe's Falls, Vt., has sent me the fol- 
lowing account of a case which occurred in his own practice. October, 
1861, Mrs. H., a robust young married woman, aged about 20 years, 

1 Toogood, Am. Journ. of Med. Sci., vol. xxxi. p. 465. 2 E. Parker, ibid. 

3 Little, New York Med. Times, Aug. 17, 1861. 

4 Yale, New York Journ. Med., vol. ii. p. 124, Nov. 1865. 



DISLOCATIONS OF HEAD OF TIBIA OUTWARDS. 825 

was driving a young horse and holding her infant in her arms, when the 
horse ran and she was thrown out. One of her legs beina; caught in the 
wheel, she was carried over three or four times in its revolutions before 
she became disengaged, holding meanwhile upon her infant with such 
firmness that it suifered no harm. 

A few hours later Dr. Downes and Dr. Burton found a complete dis- 
location of the tibia and fibula forwards, and the lower end of the femur 
could be felt under the muscles of the calf of the leg. The limb was 
shortened four inches and a half. The patella lay loosely in front of the 
femur, with its lower margin tilted forwards. 

The patient was laid upon a bed, and a perineal band made fast to one 
of the posts, while a laque was placed upon the foot and attached to a 
rope folded upon itself and forming a pulley or " Spanish windlass," such 
as is described at page 755. In this way the reduction was speedily 
and easily accomplished. Hot fomentations were subsequently applied 
for several days, the limb being kept perfectly at rest. In about three 
months she was able to do her own housework, and in a short time after 
all traces of her accident had disappeared. 

The following account of a case was sent to me by my young friend, 
Dr. Alonzo Pettit, of Elizabethport, N. J. : — 

"Joseph McGuire, laborer, set. 26, was stealing a ride upon a freight 
train upon the Central Railroad of New Jersey, on the evening of June 
19, 1874. He was sitting upon the platform of the car, with his feet 
upon the platform of the next car, his legs extended. The train slack- 
ing up at a station, before he had time to bend his knees, the cars came 
together and pushed the head of the left tibia upwards upon the femur. 

" I saw him about half an hour after the accident, and found a com- 
plete dislocation of the head of the tibia, with the patella forwards upon 
the femur. The leg was slightly flexed, and shortened two and a half 
inches. I succeeded in reducing it easily without assistance, or the use 
of anaesthetics, by grasping the leg with the left hand, the right being 
in the popliteal space, making moderate extension and flexion, and press- 
ing upon the condyles of the femur. There was considerable swelling 
and inflammation, but they yielded under the use of refrigerant lotions. 
The leg was kept extended for three weeks, during which time he suf- 
fered no pain whatever. At the end of two weeks I began the use of 
passive motion, cautiously, and after three weeks I allowed him to begin 
to walk, wearing a firm elastic knee-cap. July 22d, when I last saw 
him, he walked with a very slight halt, and could bend the knee about 
25°, and was still improving." 

§ 3. Dislocations of the Head of the Tibia Outwards. 

Occasionally, owing to a violent wrench of the knee-joint, the lateral 
ligaments upon one side or the other are ruptured, and consequently the 
joint surfaces separate somewhat from each other ; or when the limb is 
moved, the head of the tibia may slide a little forwards or backwards, or 
to either side. These are not properly examples of subluxation ; nor 
should we consider as belonging to this class the accident originally de- 
scribed by Mr. Hey as an " internal derangement of the knee-joint," but 
53 






826 



DISLOCATIONS OF THE HEAD OF THE TIBIA 



which also by some writers has been termed a " subluxation of the knee.'' 
Of this latter accident I will take occasion hereafter to speak a little 
more particularly. 

In subluxation, properly so called, if the direction of the dislocation is 
outwards, the outer condyle of the femur rests upon the inner articu- 
lating surface of the tibia, and if the direction of the dislocation is inwards, 
the inner condyle of the femur rests upon the outer articulating surface 
of the tibia. 

The signs which characterize this accident are such as cannot easily 
be mistaken. The limb is not shortened, nor is there anything espe- 
cially diagnostic in its position, since it has been found to be sometimes 
flexed, and at other times straight ; but the strong lateral projections 
made by the inner condyle of the femur on the one hand, and by the 
heads of the tibia and fibula on the other, cannot fail to inform us as to 
the true nature of the accident. 

The treatment will not differ essentially from that which has already 
been recommended in dislocation of the tibia backwards or forwards. If 
any other expedients can prove useful, they must be 
left to the judgment of the surgeon whenever the 
exigencies of the case shall demand them. 

I have already mentioned the case of N. Smith, 
who, in consequence of a fall from a window, had 
a dislocation of the right femur, tibia, and patella. 
The tibia was subluxated outwards, and the leg was 
partially flexed upon the thigh, with the toes everted. 
By moderate extension, made with my own hands, 
united with alternate flexion and extension, the bone 
was easily and promptly restored to its place. Hav- 
ing reduced the femur also, the limb was laid over a 
gently inclined plane made of pillows ; and cloths 
* fl-mmm moistened with cool water were kept constantly 

\v$}tj/ff applied to the knee for many days. Very little 

swelling followed the accident, and his recovery 
was rapid and complete. 

A man was received into the North London Hos- 
pital, with a partial dislocation of the tibia outwards, 
and although the knee was much swollen, the nature 
of the injury was easily determined. The knee was 
immovable, and the toes turned outwards. Mr. Hallam, the house sur- 
geon, reduced it by extension and counter-extension made by his own 
hands. 1 

Mr. Pitt records a similar case in a young lady, produced by a fall 
down a flight of stairs. It was reduced easily by extension and counter- 
extension. Inflammation followed, but it was finally controlled, and she 
regained the use of her limbs. 2 

In one case of subluxation, mentioned by Sir Astley Cooper, and in a 
second recorded by Bransby Cooper, the recovery of the functions of the 




Subluxation of the head 
of the tibia outwards. 



1 Hallam, Amer. Journ. Med. Sci., vol. xix. p. 251. 

2 Pitt, ibid., vol. xxxi. p. 465. 



DISLOCATIONS OF HEAD OF TIBIA INWARDS. 



827 



joint did not seem to have been so rapid ; the joint remaining unstable 
and tender for a lono- time afterwards. 1 



Fig. 341. 



§ 4. Dislocations of the Head of the Tibia Inwards. 

There is nothing peculiar in either the signs, conditions, or treatment 
of this accident, as distinguished from a dislocation outwards, to demand 
of us a special consideration. 

Sir Astley Cooper has mentioned two cases of subluxation inwards, and 
Mr. B. Cooper has added to these a third. Sir Astley remarks that in 
the first accident, the only one indeed which he had 
himself ever seen, he was struck with three circum- 
stances : first, the great deformity of the knee from 
the projection of the tibia ; second, the ease with 
which the bone was reduced by direct extension ; and 
third, by the little inflammation which followed. The 
second case of which Sir Astley speaks was commu- 
nicated to him by a Mr. Richards. In this case the 
fibula was also broken, and the reduction was accom- 
plished only after extension had been made by seve- 
ral persons for half an hour. The limb became ex- 
cessively swollen, and remained so for many weeks. 
Eighteen months after the accident the knee continued 
somewhat stiff, and there was an unnatural lateral 
motion in the joint, from the injury which the liga- 
ments had sustained. The patient referred to by 
Bransby Cooper had met with the accident by a fall 
upon the foot, with his leg bent under him ; and a 
fellow-workman had reduced the bone by extension 
and pressure. Mr. Cooper thinks that not only the 
internal lateral ligament was torn, but also some 
fibres of the vastus externus and the crucial ligaments. Violent inflam- 
mation ensued, which did not permit him to leave the hospital until after 
about two weeks. 2 Fergusson has seen two examples of unreduced sub- 
luxation inwards, in both of which the patients had regained useful 
limbs. 3 

Malgaigne mentions that Boyer, Costallat, and Key had each seen one 
similar example ; and he also enumerates two additional cases of com- 
plete luxation attended with a protrusion of the bone through an exter- 
nal wound ; in both of which the reduction was easily effected and the 
patients recovered. 4 




Subluxation of the head 
of the tibia inwards. 



§ 5. Dislocations of the Head of the Tibia Backwards and Outwards. 

In June, 1853, Henry J., of Dansville, N. Y., set. 24, was thrown by 
an enraged bull, and his left leg, being caught under the knee by the 
horns, was twisted violently. Drs. Prior, of Dansville, and Batton, of 



' B. Cooper's ed. of Sir Astley, op. cit., pp. 111-13. 2 Ibid. 

3 Fergusson. op. cit., p. 2.84. 4 Malgaigne, op. cit., torn. ii. p. 956. 



828 DISLOCATIONS OF THE HEAD OF THE TIBIA. 

Burns, were called, and found the left knee completely dislocated ; the 
tibia being displaced backwards beyond the condyles of the femur, and 
also a little outwards. The foot and leg were inclined outwards. With 
the assistance of four men, extension and counter-extension were made 
in the line of the axis of the limb, and the reduction was easily accom- 
plished. Pasteboard splints, bandages, etc., were applied to maintain 
the bones in place ; but the swelling came on rapidly, and in the evening 
these dressings w T ere removed. The limb was now laid over a double- 
inclined plane carefully padded, in order to press the upper end of the 
tibia forwards, as it manifested a constant inclination to become displaced 
backwards. This apparatus was employed six weeks, with the exception 
of two or three days, during which the limb was laid upon pillows, but 
as the pillows did not sufficiently support the back of the tibia, the 
double-inclined plane was resumed. After the removal of the plane, 
during seven weeks longer, an angular splint was kept closely applied to 
the back of the limb. 

Seven months after the accident, on the 23d of January, 1854, Dr. 
Robinson, of Hornellsville, brought the gentleman to me. I found the 
bones displaced backwards about three-quarters of an inch, and half an 
inch outwards, or to the fibular side. This was the position of the 
bones when he was sitting with his leg bent at a right angle with the 
thigh, but when he stood erect and bore some weight upon the foot, the 
outward displacement ceased, and the backward displacement only re- 
mained. It was very easy, however, in whatever position the leg might 
be, to push the bones forwards by the hands until nearly all deformity 
had disappeared. He could flex the leg to a right angle with the thigh, 
and straighten it completely, but he could not lift the foot and leg from 
the floor while sitting; with his limb extended in front of him. He was 
unable to bear sufficient weight upon his foot to use it at all in pro- 
gression, on account of the inability to fix and steady the limb, but not 
on account of any pain or soreness which it occasioned. 

It was very plain that the surgeons were not in fault for this unfor- 
tunate condition ; indeed, they seem to have exercised throughout great 
ingenuity and skill in its management. 

I directed the young man to Mr. John C. Seiffert, of Buffalo, a very 
ingenious instrument-maker, who has since succeeded, I learn, in adapt- 
ing to his knee a mechanical contrivance which enables him to walk 
quite well. 

Thomas Wells, of Columbia, South Carolina, has described a similar 
accident, the tibia being dislocated outw T ards and backwards, which ter- 
minated fatally on the fourth day in consequence mainly of exposure, 
intemperance, and neglect to apply for surgical aid. The bones were 
never reduced, and the autopsy disclosed also a fracture of the internal 
condyle of the femur. 1 

1 Wells, Amer. Journ. Med. Sci., vol. x. p. 25, May, 1832. 



, 



INTERNAL DERANGEMENT OF THE KNEE-JOINT. 829 



§ 6. Internal Derangement of the Knee-Joint. 

Syn. — " Slipping of the semilunar fibro-cartilages ;" Hey. " Partial dislocation of 
the thigh-bone from the semilunar cartilages ;" Sir Astley Cooper. " Subluxation of 
the semilunar cartilages;" Malgaigne. "Subluxation of the knee;" Erichsen. 
To these we think it proper to add, as giving rise to the same class of symptoms, 
" Floating cartilages in the knee-joint." 

We have already expressed our opinion that this accident is in no 
proper sense a subluxation of the knee ; and we should not, therefore, 
think it worth while to make any farther allusion to it, were it not 
necessary in order to enable the student of surgery to distinguish be- 
tween the phenomena which belong to it and those which belong strictly 
to subluxation of this joint. 

Symptoms. — The patient is suddenly thrown to the ground while 
walking, as if by an instantaneous loss of power in the affected limb, this 
loss of control over the limb being accompanied usually with sharp pain, 
referred to the region of the knee-joint ; or he trips his toe against some- 
thing in his path, and the toes becoming everted, the leg suddenly gives 
way under him ; in some cases it has happened when the patient was 
turning in bed, the weight of the bedclothes hanging upon the toes so as 
to occasion a strain and rotation outwards at the knee-joint, or it follows 
upon a subluxation of the joint, as in one example which I shall pre- 
sently relate. 

If the patient is walking when the accident takes place, and he falls 
to the ground, he finds himself unable to move the limb, or to stand 
upon it ; but by manipulation, the difficulty is, in most cases, as easily 
overcome as it occurred, when immediately the motions of the joint be- 
come free, and he walks off as if nothing had happened. 

When the accident has once taken place, it is afterwards exceedingly 
liable to occur from very slight causes, and eventually the knee-joint 
becomes tender and the capsule fills with synovia, indicating the exist- 
ence of subacute synovitis. 

A single example will illustrate the usual history of these cases. 

A young man, from Colesville, N. Y., set. 23, consulted me, on the 
27th of Oct. 1858, in relation to the condition of his knee-joint. He 
stated that on the 13th of Aug. 1858, while standing with the whole 
weight of his body resting upon the left leg, a mate struck him on the 
inside of the lower end of the left femur. The blow was made with the 
palm of the hand, but with sufficient force to throw him down. It was 
immediately noticed that the tibia was partially dislocated inwards at 
the knee-joint. The whole lower part of the limb was inclined outwards. 
A person present in the room seized upon the foot and by extension 
easily brought it back to place ; the bone resuming its position with an 
audible snap. After this he continued to walk about until night. Two 
days after, the knee had become so much inflamed that he was obliged 
to take to his bed, on which he was confined three weeks. Gradually 
the swelling subsided, and in about five weeks after the accident he be- 
gan to walk on crutches. On the 23d of Sept. he was walking in the 
store without crutches, when he suddenly felt a sensation of slipping in 
the joint, and he fell to the floor as if he had been tripped up. At the 



830 DISLOCATIONS OF THE HEAD OF THE TIBIA. 

time when he called upon me, this had happened many times, but had 
never been attended with pain. The joint was filled with synovia, and 
tender, yet I could distinctly feel a hard body just to the inside of the 
ligamentum patellae, and which moved freely under the finger. 

Pathological Anatomy. — The same class of symptoms, with only very 
slight modification, belongs probably to several varieties of " internal 
derangement of the knee-joint ;" and first it will be remembered that the 
semilunar cartilages upon which the margins of the condyles of the femur 
rest, are attached to the tibia by several ligaments ; but when, from 
relaxation or a violent strain, any one of these ligaments becomes elon- 
gated or gives way, the portion of cartilage which it restrains is per- 
mitted to become partially displaced, and by interposing its thick margin 
between the deeper articulating surfaces the bones are separated and the 
muscles lose their control over the joint ; second, these ligaments may 
not only yield, but a fragment of one of the cartilages may become ac- 
tually broken off from the main portion ; third, the femur may perhaps 
escape behind some portion of an interarticular cartilage, and thus, in- 
stead of the cartilage placing itself between the joint surfaces, the femur 
itself may have thrust it into this position ; fourth, a cartilage, or some 
portion of a cartilage, may become hypertrophied, and thus give rise to 
the symptoms described ; fifth, in other cases still, a bony, cartilaginous, 
fibrinous, or calcareous growth or concretion forming within the joint, 
and, if originally attached, becoming separated from the capsule, may 
move about more or less freely, and give rise to the same class of symp- 
toms which we have described. 

This last variety has generally been described under the name of 
"floating cartilages;" but since these bodies are not always cartilagi- 
nous, and especially since they do not always by any means move so 
freely as to be properly designated as " floating," the term is less appro- 
priate than that originally given by Hey, and which we have chosen to 
adopt. 

Treatment. — For the purpose of obtaining immediate relief, it is gene- 
rally sufficient to flex the leg completely and then suddenly extend it, or 
to combine this motion with a slight twisting or rocking of the knee-joint. 
Sometimes this experiment has to be repeated several times before it is 
completely successful, and in a few instances it has failed altogether. I 
think I must have met with ten or twelve examples in the course of my 
practice, and in no instance has the sudden flexion and extension of the 
limb failed to overcome the difficulty. 

As to the question of subsequent treatment, especially as to whether 
it is proper to attempt their extirpation when they are found to be loose, 
or to make any other surgical interference, I prefer to leave its con- 
sideration to those general treatises upon surgery where it more properly 
belongs. 



DISLOCATIONS OF LOWER END OF TIBIA INWARDS. 831 



CHAPTER XIX. 

DISLOCATIONS OF THE LOWER END OF THE TIBIA 
(TIBIO-TARSAL). 

Syn. — "Dislocations of the ankle-joint ;" Chelius and others. 

The tibia may be dislocated at its lower end in four directions ; namely, 
inwards, outwards, fonvards, and backwards. Most of these dislocations 
complicate themselves with fractures of the fibula or of the tibia, or with 
fractures of both bones. 

Dupuytren, Malgaigne, and a few other surgeons have reported ex- 
amples also of dislocations forwards and inwards. 

Boyer, with a majority of the French writers, and several English and 
German surgeons, speak of these dislocations as belonging to the foot; 
consequently the outward dislocation of Boyer is the inward dislocation 
of Sir Astley Cooper, Malgaigne, myself, and others, who prefer to re- 
gard the tibia as the bone dislocated. 



§ 1. Dislocations of the Lower End of the Tibia Inwards. 

Syn. — " Inward tibio-tarsal luxations ;" Malgaigne. " Dislocations of the foot out- 
wards ;" Boyer and others. 

Causes. — This dislocation is occasioned generally by a fall from a 
height, upon the bottom of the foot, the foot receiving at the same 
moment a sufficient inclination outwards to determine the main force of 
the impulse toward the inner side of the ankle. It may be produced 
also by a blow T received directly upon the outside of the leg just above 
the ankle, or by a violent twist or wrench of the foot outwards. 

Pathological Anatomy. — I have already, in the chapter on fractures 
of the fibula, stated my opinion that a large majority of those accidents 
which have been called inward 

and outward dislocations of the Fig. 342. 

tibia, were merely examples of 
lateral rotation of the astraga- 
lus within the half ginglymoid 
and half orbicular socket formed 
by the lower extremities of the 
tibia and fibula ; and that true 
dislocations, either partial or 
complete, are at this joint and 
in these directions very rare 
occurrences. We shall continue, 
however, in accordance with the 
general practice of writers, to 

Call them all dislocations, Whe- Dislocation of the lower end of the tibia inwards. 




882 DISLOCATIONS OF LOWER END OF THE TIBIA. 

ther the astragalus simply rotates on its axis, or is displaced laterally 
and horizontally from the tibia. 

In the most common form of the accident, then, when the foot is vio- 
lently twisted outwards, the astragalus becomes tilted upon its outer and 
upper margin in such a way that this margin slides inwards and places 
itself underneath the middle portion of the lower articulating surface of 
the tibia ; its upper and inner margin descends toward the extremity of 
the malleolus internus, and the outer surface of the astragalus presents 
obliquely upwards and outwards, instead of directly outwards as it would 
do in its natural position. This cannot occur without a rupture of the 
internal tibio-tarsal ligaments, or a fracture of the malleolus internus, or 
both ; indeed, a fracture of the internal malleolus is a very common cir- 
cumstance in connection with this form of dislocation. Much more fre- 
quently, however, the fibula itself gives way at a point within from two 
to five inches of its lower extremity ; or sometimes the fracture in the 
fibula occurs through that portion which forms the malleolus externus. 
For more particular information as to the causes and relative frequency 
of these fractures, I refer the reader to the chapter on fractures of the 
fibula. 

Rarely it happens that, instead of this lateral rotation of the astrag- 
alus, there occurs a true lateral displacement of the tibia inwards upon 
the astragalus, and the outer portion of the lower articulating surface 
of the tibia comes to rest upon the inner portion of the upper articu- 
lating surface of the astragalus ; or it may slide completely oif in the 
same direction ; a result which is usually attended with a laceration of 
the muscles and integuments, converting the accident into a compound 
dislocation. In some cases this extreme displacement occurs without 
such laceration. 

In this form of the accident, the true lateral luxation, the fibula may 
remain unbroken and undisturbed, the tibia merely having become dis- 
placed inwards ; or the fibula may give way also above the articulation, 
while the malleolus internus, and the internal lateral ligaments, are 
equally liable to rupture as in the other form of the accident. 

Sometimes, in addition to these complications, the lower end of the 
tibia is found to be broken obliquely upwards and outwards from the 
articulating surface, leaving that fragment attached to the fibula which 
corresponds to the inferior peroneo-tibial articulation. 

Symptoms. — The foot is more or less violently abducted, the sole of 
the foot presenting downwards and outwards instead of directly down- 
wards; the malleolus internus projects strongly at the inner side of the 
joint ; and at the outer side there is a corresponding depression, gener- 
ally most marked a little above the articulation near the point of frac- 
ture in the fibula. The pain is very great, and the foot is immovably 
fixed so far as the volition of the patient can determine motion, but the 
surgeon can generally move it pretty freely, yet not without causing a 
great increase of the pain. When the dislocation is complete, and the 
fibula is also broken, the limb becomes slightly shortened. 

Treatment. — When the accident is of the nature of a simple rotation 
of the astragalus upon its axis, the reduction is often accomplished with 
the greatest ease by seizing upon the foot and forcibly adducting it. 



DISLOCATIONS OF LOWER END OF TIBIA INWARDS. 833 

Not unfrequently the patient himself, or some other person who is 
present, has effected the reduction before the surgeon is called. In 
other cases, and especially when it partakes of the nature of a true dis- 
location, much difficulty is sometimes experienced in the reduction. The 

Fig. 343. 




Dislocation of the lower end of the tibia inwards. 



surgeon ought then to flex the leg upon the thigh, in order to relax the 
gastrocnemii muscles, and holding the foot midway between flexion and 
extension, he should pull steadily upon it with his own hands, while an 
assistant makes counter-extension and supports the limb with his hands, 
grasping the thigh above the knee. At the same moment lateral pres- 
sure should be made upon the projecting bone in the direction of the 
articulation. It is of some use, also, to occasionally flex and extend the 
limb moderately, and to give to the foot a gentle rocking motion. If 
more force is needed, it may be applied by placing the limb over a firm 
double-inclined fracture-splint, and making the extension by the aid of a 
screw attached to the foot-board, as we have suggested in certain cases 
of dislocation at the knee. Or we may employ the pulleys after the 
manner represented in the accompanying drawing, Fig. 344. 

Charles Sauer, aged about thirty years, while carrying a weight upon 
his shoulders, on the 6th of May, 1854, slipped upon the sidewalk, and 
fell, dislocating the left tibia inwards, and fracturing the fibula four 
inches from its lower end. I was in attendance soon after the accident 
occurred, and found the tibia projecting inwards, with the other symp- 
toms usually accompanying a simple rotation of the astragalus upon its 
Seizing the foot with my hands, and flexing the leg, while an 



axis. 



834 



DISLOCATIONS OF LOWER END OF THE TIBIA 



assistant held up the thigh and made counter-extension, I had scarcely 
begun to pull upon the foot before the reduction was effected. Dupuy- 
tren's splint was at once applied, and the subsequent inflammation was 
so trivial as scarcely to deserve notice. In six weeks the limb was 
sound, and free from all anchylosis. 



Fig. 344. 




In my report on dislocations, made to the New York State Medical 
Society for the year 1855, I have mentioned twelve similar examples, 
in addition to some examples of compound dislocations, all of which 
were easily reduced, but the results were not always so favorable. 

If, as rarely happens, the tibia is broken obliquely into the joint, 
the complete reduction of the dislocated tibia may be found impossible, 
owing to the obstacle presented by the displaced fragment. 

The following I am disposed to regard as examples of dislocation 
accompanied with fracture of the tibia within the articulation: — 

Brockway, of Cortland, .N. Y., aged about twenty-seven years, con- 
sulted me, at my office, a few years since, in relation to the condition of 
his foot. I found the tibia dislocated inwards, and projecting more 
than an inch beyond the astragalus; the sole was turned outwards, 
compelling him to walk upon the inside of his foot ; the fibula was bent 
inwards against the tibia, at a point about four inches above the ankle, 
which seemed to have been the seat of fracture of this bone. He stated 
to me, that immediately after the receipt of the injury, which Avas occa- 
sioned by a fall from a height upon the bottom of his foot, he had con- 
sulted a surgeon, Dr. A. B. Shipman, of Cortland, and that although 
Dr. Shipman made repeated and violent efforts to effect the reduction, 
he had been unable to do so. Indeed, the bone had never been removed 
from the position in which it was at first placed. 

J. Borland, of Erie Co., N. Y., set. 31, fell under a rolling log, and 
dislocated his left tibia inwards, breaking off the internal malleolus, 
and fracturing the fibula four inches from its lower end. Dr. Sweet- 
land, an old and experienced practitioner, was immediately called, who, 
with another surgeon, failed, after repeated efforts, to reduce the dislo- 
cation. I saw the patient, in consultation with these gentlemen, twenty- 



DISLOCATIONS OF LOWER END OF TIBIA INWARDS. 835 

four hours after the accident. The foot and ankle were somewhat 
swollen and discolored. The lower end of the tibia projected so far 
inwards as to threaten a rupture of the skin: the foot was strongly 
everted. We first Hexed the leg upon the thigh, and made extension 
with our hands, in the manner I have already directed. This we con- 
tinued several minutes ; finally moving the limb in various directions, 
and adding forcible pressure upon the inside of the projecting tibia. 
We then placed the leg over a double-inclined plane, and, securing it 
firmly in place, we attached a screw to the foot through a sandal and 
gaiter, and while the leg was well flexed upon the thigh, Ave renewed 
the extension and lateral pressure. This was continued, with the appli- 
cation of more or less power, during half an hour, meanwhile changing 
the position of the limb occasionally by varying the angle of the splint. 
Our efforts were prolonged in all more than one hour, when, as we had 
made no impression upon the bone, and the patient had repeatedly im- 
plored us to desist, the attempt was given over. The end of the tibia 
seemed to rest partly upon the astragalus, and the extension was plainly 
all that was demanded, but the obstacle was beyond doubt within the 
articulation, or rather between the tibia and fibula. 

Four weeks after the accident, Mr. Borland walked on crutches, and 
during a year he was compelled to use a cane, but since that time a 
period of twelve years, he walked without any artificial support. For 
a year or two he felt a yielding in his ankle, as the weight of his body 
settled upon his limb ; but this gradually ceased, and for some years 
past he has walked without any halt, and seems to step as firmly as 
before the accident. The foot still inclines outwards ; the tibia projects 
inwards one inch, and the broken ends of the fibula can be felt resting 
against the tibia, where they are reunited. 

Not long since, I had occasion to amputate a limb for a compound 
dislocation inwards, at the ankle-joint, and the possibility of this frac- 
ture was confirmed by the dissection. About one-third of the outer 
portion of the articular surface was broken off obliquely, and the frag- 
ment was lying so displaced that a reduction would have been rendered 
impossible. 

Dr. Townsend, of Boston, has reported a case of compound dislo- 
cation, in which also amputation became necessary; and, with other 
injuries, the dissection showed a fragment from the outer margin of 
the tibia, one inch and a half long, and one inch thick at its widest 
part, with a very sharp point, displaced, and lying almost transversely 
over the astragalus. 1 

For a more full account of the prognosis and the general manage- 
ment of these cases subsequent to the reduction, I beg again to refer 
the reader to the chapter on fractures of the fibula ; and for my views 
in relation to the treatment of compound dislocations of the ankle-joint, 
I will refer also to the chapter on compound dislocations of the long 
bones. 



1 Townsend, Mass. Hosp. Reports, Boston Med. and Surg. Journ., vol. xxxiii. p. 
277. 



836 



DISLOCATIONS OF LOWER END OF THE TIBIA 



§ 2. Dislocations of the Lower End of the Tibia Outwards. 

Syn. — "Outward tibio-tarsal luxation;" Malgaigne. "Dislocations of the foot 
inwards," of others. 

The causes are the same or similar to those which are known gen- 
erally to produce dislocations inwards ; only that the force of the con- 
cussion or the direction of the rotation must have been reversed. 

The external lateral ligaments, peroneo-tarsal, are either ruptured, 
or the lower portion of the fibula gives way, or both of these circum- 
stances may have happened ; 
FlG - 345 - while the internal malleolus may 

also yield to the shock and to 
the weight of the body now rest- 
ing upon it. The nature of the 
accident may vary also in respect 
to the relative position of the ar- 
ticular surfaces ; the astragalus 
may simply rotate on its inner 
and upper margin, or the tibia, 
with the fibula, of course, may 
actually slide outwards until the 
lower end of the tibia more or 
less completely abandons the 
upper surface of the astragalus. 
The modes of reduction, and 
the general principles of treat- 
ment subsequently, will not differ 
from those which we have men- 
tioned as suitable for dislocations 
in the opposite direction. The 
examples which have fallen under 
my observation are not numer- 
ous, but the reduction has always 
been easily effected. Thus, a 
man, ast. 21, fell from a scaffold- 
ing, alighting upon his feet. He 
says that his left foot struck the 
ground obliquely, and upon its 
outer margin. I found the fibula 
projecting very strongly out- 
wards, evidently carrying with it the tibia ; the malleolus interims was 
broken off, and the foot forcibly turned inwards. Without either flexing 
the leg upon the thigh or calling to my aid any degree of counter-exten- 
sion except what was made by the weight of the body, I grasped the 
foot and drew upon it geutly, while at the same momsnt I rotated the 
foot outwards. Immediately the bones resumed their places. 

In June of 1846, Henry Wilson, get. 38, consulted me in relation to 
his foot, which he said had been dislocated four weeks before. He had 
fallen upon the outside of his foot and turned it suddenly inwards, so 




Dislocation of the lower end of the tibia outwards. 



DISLOCATIONS OF LOWEE END OF TIBIA FOEWARDS. 837 

that when he looked at it he found the sole presenting toward the oppo- 
site side. Seizing upon it with both hands, he pressed it forcibly out- 
wards, and the reduction immediately took place with a snap. Very 
little soreness followed, nor was he confined to his house a single day. 
He had continued to walk about with only a slight halt in his gait, nor 
would he have thought it necessary to consult me at all except that the 
tenderness had not yet disappeared. He was not aware that the fibula 
had been broken also, until I called his attention to the fact. The frac- 
ture had taken place two inches above the ankle ; and although it was 
already united, the depression occasioned by its having fallen in some- 
what toward the tibia was very plainly felt and recognized. 

§ 3. Dislocations of the Lower End of the Tibia Forwards. 

Syn. — "Forward tibio-tarsal luxations;" Malgaigne. "Dislocations of the foot 
backwards," of others. 

Causes. — This dislocation may be produced by a violent extension 
of the foot upon the leg ; as, for example, when, the foot being engaged 
under a piece of timber, the body falls backwards to the ground ; or 
it may be caused by a fall upon the bottom of the foot, the foot resting 
upon a slightly inclined plane. It may be caused also by any of that 
class of accidents which are known to produce fractures of the fibula with 
fracture of the malleolus internus, or fracture of the fibula with rupture of 
the internal lateral ligament ; for example, by a fall upon the bottom of the 
foot, or upon the inside of the sole, followed immediately by an outward 
twist of the foot. In these cases the luxation of the foot backwards, or, 
as it is generally found to be, the semi-luxation, may be consecutive upon 
the accident, and the result only of contraction of the gastrocnemii. It 
may, therefore, occur immediately after the fracture has taken place, or 
not until after the lapse of several days. 

Pathological Anatomy. — The displacement may be very slight, so 
that the end of the tibia is only a little advanced upon the astragalus ; 
or it may be such that the tibia rests one- half upon the naviculare and 
one-half upon the astragalus, or it may even desert the astragalus en- 
tirely. The fibula may at the same time be broken at any point, but it 
is generally broken tw T o or three inches above its lower extremity. The 
malleolus internus is also sometimes broken, but more often the internal 
lateral ligament is torn. Still more rarely a fracture occurs through the 
posterior margin of the articular surface of the tibia. 

Symptoms. — The length of the foot in front of the tibia is diminished, 
while the projection of the heel is correspondingly increased ; the toes 
are turned downwards and the heel drawn upwards, and fixed in this 
position ; the end of the tibia may generally be distinctly felt in front of 
the astragalus ; the extensor tendons of the toes are sharply defined, 
while the tendo Achillis is curved forwards, and tense. 

At the regular meeting of the New York Pathological Society, No- 
vember 22, 1865, I presented a specimen obtained from the dissecting- 
room of the Belle vue Hospital College. The history of the case was 
unknown. 



838 DISLOCATIONS OF LOWER END OF THE TIBIA. 

Before dissection, the foot was observed to be turned outwards, and 
shortened in front of the tibia, while there was a corresponding length- 
ening of the heel. The specimen, after dissection, disclosed a fracture 
of the internal malleolus half an inch above its lower end, and a fracture 
of the fibula a little above its lower end. The tibia was displaced for- 
wards about three-quarters of an inch, so that only the posterior half of 
its lower end rested upon the articular surface of the astragalus, and at 
the point of contact with the astragalus a new socket was formed in the 
tibia, concave upwards, half an inch deep, and presenting an appearance 
as if the posterior lip of the lower end of the tibia had been broken off 
and had become displaced upwards. It was supported by a broad but- 
tress of bone. It is not certain, however, but that this appearance was 

Fig. 346. Fig. 347. 





Partial dislocation of the tibia forwards, Partial dislocation of the tibia forwards, with frac. 

with fractures of malleolus internus, and ture of the malleolus internus, and fibula, 

fibula. Skeleton. 

occasioned solely by the long-continued pressure of the tibia upon the 
astragalus at this point. The fragments of the malleolus internus, and 
the lower fragment of the fibula, remained attached to their upper frag- 
ments and to the two sides of the astragalus in their normal positions, 
consequently each fragment was inclined downwards and backwards at 
an angle of 45°. The lower fragment of the fibula was driven upwards, 
also, but both of the fractures were firmly united. This specimen is 
now in the museum of the Belle vue Hospital College. 

At the same meeting of the Pathological Society I reported the case 
of Mary Conlan, aet. 38, admitted to Bellevue Hospital, November 13, 
1865, having been thrown three days before from a street car. She 
could give no account of the manner in which she fell. I saw her 
November 16th. The limb was then much swollen, and I diagnosticated 
a fracture of the lower end of the fibula. (It had been supposed to be 
a mere sprain up to this time.) The limb was directed to be wet with 
cool water, and to rest upon a pillow. From this time I looked at it 
occasionally, to see whether the swelling had sufficiently subsided to 
warrant the application of a splint. November 20th it was examined 
again carefully by the house surgeon, Dr. Farrall, but no displacement 






DISLOCATIONS OF LOWER END OF TIBIA FORWARDS. 839 

was noticed. November 23d I found the lower end of the tibia dis- 
placed forwards, and ascertained, also, that the internal malleolus was 
broken at its base. The dorsum of the foot, measuring from the front of 
the tibia to the end of the great toe, was shortened half an inch. The 
heel was lengthened. 

There can be no doubt that in this case the dislocation occurred sub- 
sequent to the fracture, and that it was caused by the contraction of 
the gastrocnemii. I reduced the dislocation a day or two later, and 
maintained it in position by the method which I shall presently describe. 

Dr. Voss reported to the Society a similar case which had come 
under his notice, and Dr. Buck remarked that he also had met with 
such examples. 1 

In May, 1878, I found in my wards at Bellevue an old subluxation of 
this character in the person of Catharine Brady, set. 30 ; the cause of 
which I was unable to ascertain precisely. 

Dr. Prince, of Illinois, has reported a case of this character, which, 
remaining displaced, led to a prosecution for damages. A lady, set. 
40, met with an accident, August 31, 1863, which resulted in a fracture 
of the fibula near its lower end, and a partial dislocation of the tibia 
forwards to the extent of one inch. The toes were not pointed down- 
wards, but the foot had its natural angle with the leg. Nearly three 
months after the accident, Dr. Prince, assisted by two other surgeons, 
broke up the adhesions, and reduced the bones to their natural positions. 2 

Treatment. — The reduction is to be attempted by flexing the leg upon 
the thigh, and making extension from the foot, while, at the same mo- 
ment, pressure is made upon the front of the tibia and against the heel. 
When the bone begins to slide into place, the foot should be forcibly 
flexed upon the leg. A slight lateral motion or rotation in either direc- 
tion may assist in restoring the bones to place. 

In general, the dislocation has been easily reduced, but in a majority 
of the examples recorded great difficulty has been experienced in main- 
taining the reduction ; and in a few cases it has been found impossible 
to do so. 

In order to maintain the reduction, the leg, flexed upon the thigh, 
may be laid on its back in a box ; and the foot supported firmly against 
a foot-piece placed at a right angle with the box. In this position, the 
weight of the leg will tend somewhat to overcome the action of the mus- 
cles, which are disposed to displace the foot backwards. Generally it 
will be found necessary to make additional pressure directly upon the 
front of the leg above the ankle ; which, in order that it may not prove 
mischievous, must be effected with some soft material, and must be ap- 
plied over a broad surface. Perhaps nothing will better answer these 
indications than to pass a cotton band, six or eight inches in width, 
through slits or mortises in the sides of the box ; these slits being of a 
width equal to the width of the band, and placed at a point sufficiently 

1 New York Journ. Med., April. 1866, p. 40. 

2 Cincinnati Journ. Med., April, 1867, p. 202. See also Todd's Cyclopedia of 
Anat. and Phys. ; Adams on Ankle-Joint, p. 160 et seq. 



8-10 DISLOCATIONS OF LOWER END OF THE TIBIA. 

below the level of the spine of the tibia, so that when the band is made 
fast underneath the box, it shall press the leg firmly backwards. To pre- 
vent the heel from suffering in consequence of this pressure, it also should 
be supported, or suspended by another band passing underneath the heel 
and fastened above to the top of the foot-board. 

The plaster-of-Paris dressing, also, answers the purpose exceedingly 
well in these cases ; indeed, as I have explained more fully in connection 
with the subject of Pott's fracture, I must regard it as the most effective 
means for preventing these accidents, as sequences of this fracture; and 
as the most certain means for retaining the bones in position when, the 
displacement having actually occurred, they are again put in place. 

Dupuytren relates the following example of this accident: — 

Pierre Froment, set. 33, was carrying a heavy weight upon his back 
and had his right foot in advance, when by accident he came suddenly 
in contact with a beam placed across his path. Under the fear of being 
precipitated forwards, he made a sudden effort to throw his body back- 
wards, by which he lost his balance, and fell with the point of the left 
foot inclined inwards and forwards, and his whole weight was thrown 
first on the outer side, and then on the front of the ankle-joint. 

On examination, the leg seemed to be planted upon the middle of the 
foot ; the toes were directed downwards and the heel drawn up. On 
the instep there was a large bony prominence, over which the extensor 
tendons of the toes were stretched like tense cords. Behind the joint 
was a deep hollow, at the bottom of which the tendo Achillis could be 
felt forming a tense, resisting, semicircular cord, with its concavity di- 
rected backwards. The fibula was also broken ; the lower end of the 
lower fragment remaining attached to the foot, while the upper end of 
the same fragment was carried forwards by the displacement of the tibia, 
so that it lay nearly horizontally, with its broken extremity directed 
forwards. 

Dupuytren directed one assistant to fix the leg, and a second to make 
extension from the foot, while Dupuytren himself, standing on the outer 
side of the limb, forced the heel forwards and the tibia backwards. The 
first attempt succeeded partially, and the second completed the reduction. 
The limb was then placed in the apparatus employed by this surgeon for 
a fractured fibula, which we have before described, and laid on its outer 
side in a semiflexed position. The patient recovered rapidly, and in 
little more than a month he was able to walk. 1 

But such fortunate results have not usually been observed ; indeed, 
Dupuytren encountered much more serious difficulties in two other cases 
which came under his own notice, one of which he has himself recorded. 
This was in the person of a woman get. 48, who was brought to the Hotel 
Dieu in 1815, the accident having just happened from a slip in going 
down stairs. The fibula was broken, and also a fragment was broken 
from the tibia. The house surgeon reduced the bones, and placed the 
limb in the ordinary apparatus for broken legs ; but on the following day 
Dupuytren found them reluxated, and laid the limb on his own splint, 
but the pressure requisite to keep the tibia in place soon induced slough- 

1 Dupuytren, Injuries and Dis. of Bones, London ed., p. 278. 



DISLOCATIONS OF LOWER END OF TIBIA BACKWARDS. 841 

] ng, ulceration, and abscesses, and after four months' treatment, during 
which time the tibia had been repeatedly displaced, she left the hospital, 
able to use her limb, but with a certain amount of incurable deformity. 1 
Malgaigne mentions the third example as having been seen by himself 
in Dupuytren's service in 1832, in which case the attempt to maintain 
the reduction by a tourniquet resulted in gangrene and finally the death 
of the patient. 2 Earle lost a patient after amputation made on the eighth 
day. The tibia could not be kept in place, and the amputation became 
necessary on account of the final protrusion of the bone through the in- 
teguments, which had sloughed. 3 

§ 4. Dislocations of the Lower End of the Tibia Backwards. 

Syn. — "Backward tibio-tarsal luxations;" Malgaigne. " Dislocations of the foot 
forwards," of others. 

More rare than the dislocations forwards, Malgaigne has, nevertheless, 
succeeded in collecting five examples. 

They appear to have been produced, generally, by a cause the reverse 
of that which we have seen to produce in certain cases the preceding 
dislocation. Thus, while the dislocation forwards is produced sometimes 
when the foot is in violent extension, this dislocation has occurred, in at 
least two or three cases, when the foot was forcibly flexed upon the leg. 



Fig. 348. 



Fig. 349. 





Dislocations of the lower end of the tibia backwards. 

The symptoms are strongly marked and characteristic. The length of 
the foot from the tibia to the ends of the toes is increased one inch or 
more, the heel being correspondingly shortened, or rather wholly obliter- 
ated ; a portion of the articulating surface of the astragalus may be dis- 
tinctly felt in front of the tibia ; the posterior surface of the tibia touches 
the tendo Achillis ; the leg is shortened, and the malleoli approach the 
sole of the foot. 



Dupuytren, op. cit., p. 276. 
Malgaigne, op. cit., p. 1044. 
54 



2 Malgaigne, op. cit., p. 1044. 



842 DISLOCATIONS OF UPPER END OF THE FIBULA. 

In most cases one or both of the malleoli have been broken ; and R. 
W. Smith, who has reported one of the examples alluded to, believes 
that the dislocation is never complete. 

Reduction should be attempted by a method similar to that which has 
been recommended in all the other dislocations of the ankle, only with 
such modification as the peculiarities of the case must necessarily suggest. 



CHAPTEE XX. 

DISLOCATIONS OF THE UPPER END OF THE FIBULA. 

Syn. — " Luxations of the superior peroneo-tibial articulation ;" Malgaigne. 

Surgeons have frequently described a condition of the peroneo-tibial 
articulation in which the ligaments have become relaxed, giving a preter- 
natural mobility to the head of the bone. It is also not unfrequently 
displaced upwards, in consequence of an oblique fracture of the tibia. 
I have myself seen several examples of both these accidents ; but simple 
traumatic dislocations, which can only occur forwards or backwards, are 
very rare. 

I 1. Dislocations of the Upper End of the Fibula Forwards. 

Malgaigne has collected three examples of this luxation, uncomplicated 
with any other accident ; and not, apparently, due to any abnormal con- 
dition of the ligaments, two of which, at least, seemed to have been pro- 
duced by the violent action of the muscles which are attached to the an- 
terior face of the fibula. The third example, reported by Thompson in 
the London Lancet} permits a doubt as to whether the displacement was 
occasioned by muscular action, or by a direct blow upon the part. 

The signs which characterize the anterior luxation are the absence of 
the head of the fibula in its natural position, and its presence in front, 
near the ligamentum patellae ; the altered direction of the biceps flexor 
cruris muscle ; and, in one case, considerable deformity in the shape and 
position of the leg has been observed. 

Thompson and Jobard were unable to accomplish the reduction while 
the leg was extended upon the thigh, but succeeded readily after having 
flexed the leg. On the other hand, Savournin succeeded with the leg 
extended, but with the foot flexed upon the leg. Malgaigne, to whom I 
am indebted for these observations, thinks, that flexion of the leg, com- 
bined with flexion of the foot, would render the reduction more easy. 

In whatever position the limb is placed, the surgeon must rely chiefly 
upon forcible pressure made with the fingers against the front and upper 
portion of the displaced bone. 

1 Op. cit., 1850, vol. i. p. 385. 



OF UPPER END OF FIBULA BACKWARDS. 843 

J. E. Hawley, of Ithaca, N. Y., late Professor of Surgery in the 
Geneva Medical College, has furnished me with a brief account of a case 
which came under his own observation. 

On the 29th of March, 1854, Bambak, while vaulting upon the paral- 
lel bars in a gymnasium, unintentionally made a complete somersault, 
and fell with his right foot upon the edge of a plank. Dr. Hawley, who 
was immediately called, found his right leg semi-flexed and immovably 
fixed. The head of the fibula was plainly felt in front of its natural 
position, near the ligamentum patellae. The patient was suifering the 
most intense pain. Extension and counter-extension were made, and 
while the doctor was pressing with both of his thumbs upon the head of 
the fibula, it went into its place with an audible snap. The relief was 
instantaneous. Complete rest was observed for a few days, while cooling 
lotions were constantly applied, and within a week he was able to attend 
to his usual duties. 



§ 2. Dislocations of the Upper End of the Fibula Backwards. 

Sanson has recorded one example, in which the passage of the wheel 
of a carriage across the upper part of the leg, precisely on a level with 
the peroneo-tibial articulation, ruptured the ligaments which bind the 
fibula to the tibia, and caused a displacement, which, however, seems to 
have been spontaneously overcome. Nevertheless, there remained a pre- 
ternatural mobility, permitting the fibula to be pushed easily backwards 
or forwards upon the tibia. 

I have found only two other cases of backward dislocation, one of which 
is related by Dubreuil. A man, set. 62, in order to save himself from 
falling, sprang suddenly, with his right leg in a position of extreme ab- 
duction, and at the same moment he experienced a severe pain in the 
region of the peroneo-tibial articulation. The head of the fibula was 
found to be thrown backwards, and formed under the skin a marked prom- 
inence ; the foot was drawn outwards, and the whole outside of the limb 
became cold and numb. Dubreuil flexed the leg moderately, and press- 
ing the head of the fibula from behind forwards, the reduction was easily 
effected. On the following day, the limb having been straightened, the 
dislocation was found to be reproduced. It was again replaced, and 
the knee covered with a leather cap, secured moderately tight. After 
twelve days of complete rest, the knee was moved gently, and on the 
seventeenth day the patient walked with the help of a cane. For some 
time the leg had a tendency to incline outwards ; but in about three 
months the cure was perfectly established. 1 

It is probable that in this case the dislocation resulted from the violent 
action of the biceps flexor cruris. Such, at least, is the opinion of both 
Dubreuil and Malgaigne, and I see no reason to question the correctness 
of their theory. 

The other example has been reported by Dr. Jos. G. Richardson, 
resident physician to the Pennsylvania Hospital. John Dixon, aet. 9, 

1 Malgaigne, op. cit., torn. ii. p. 386. 



844 INFERIOR PERONEOTIBIAL ARTICULATION. 

fell five feet and struck upon the outside of the left knee. When ad- 
mitted to the hospital, the leg was partially flexed and the toes a little 
everted, and he was unable to flex or to extend the limb completely. 
The head of the fibula was seen three-quarters of an inch behind its 
natural position, and the biceps was felt distinctly attached. There 
was no other lesion. The reduction was easily accomplished by press- 
ing with the fingers upon the inner and back part of the fibula, thrusting 
it outwards and forwards. A compress and bandage were applied, and 
the limb placed at rest. The reduction continued complete, and after a 
few days he was permitted to use the limb. 1 



CHAPTER XXI. 

DISLOCATIONS OF THE INFERIOR PERONEO-TIBIAL 
ARTICULATION. 

Nelaton relates the only example of a simple luxation of this articu- 
lation of which we have any information. The patient who was the 
subject of this accident presented himself at the hospital under the 
care of M. Gerdy on the thirty-ninth day after the accident, which had 
been occasioned by the passage of the wheel of a carriage obliquely 
across the leg in such a manner as to push the malleolus externus 
directly backwards. The lower end of the fibula was in almost direct 
contact with the outer margin of the tendo Achillis ; the outer face of 
the astragalus, abandoned by the fibula, could be distinctly felt in 
nearly its whole extent ; the foot preserved its natural position ; and he 
could walk pretty well, only that he was obliged to step with some care. 
M. Gerdy believed that the bone was too firmly fixed in its new position 
to be moved, and therefore made no attempt at reduction. 

1 Richardson, Ainer. Journ. Med. Sci., April, 1S63. 



DISLOCATIONS OF THE ASTRAGALUS. 



845 



CHAPTEE XXII 

TARSAL LUXATIONS. 



§ 1. Dislocations of the Astragalus. 

Syn. — "Double dislocations of the astragalus ;" Malgaigne. 

The astragalus may be dislocated forwards, outwards, inwards, back- 
wards ; or it may be dislocated obliquely in either of the diagonals be- 
tween these lines ; it may be simply rotated upon its lateral axis, without 
much, if any, lateral displacement; and, finally, it has been occasion- 
ally driven between the 

Fig. 



tUifSb 




Dislocation of the astragalus outwards. Anatomical relations. 



tibia and fibula, tearing 
away the intermediate 
ligaments, and generally 
fracturing one or both 
bones of the leg. 

Causes. - — The causes 
which have been found 
chiefly operative in the 
production of this disloca- 
tion are very much the 
same as those which pro- 
duce, under other circum- 
stances, a dislocation of 
the lower end of the tibia. 
Thus, a fall from a height upon the bottom of the foot, accompanied 
with a violent abduction, adduction, flexion, or extension, may deter- 
mine a dislocation of the astragalus inwards, outwards, backwards, or 
forwards. Sometimes it is accomplished by a mere wrenching and 
twisting of the foot in machinery, or in the wheel of a carriage, or by 
being caught between two irregular bodies. It may be produced also 
by a direct blow. 

Symptoms. — The great prominence occasioned by the displacement 
of the bone in either of these several directions, accompanied generally 
with more or less lateral deviation of the foot, is alone sufficient to in- 
dicate the true nature of the accident. In some cases, also, the foot is 
forcibly flexed or extended ; the leg is shortened in consequence of the 
tibia having fallen down upon the calcaneum ; the superincumbent skin 
and tendons are rendered tense ; blood is effused, and swelling speedily 
occurs. In the backward dislocation, the position of the foot is not 
much changed, but the tibia being slightly carried forwards, the length 
of the dorsal aspect of the foot is proportionably diminished. 

Such are the symptoms which plainly enough indicate the dislocation 



846 



TARSAL LUXATIONS. 



in the most simple cases ; but in a majority of the examples which have 
been seen, the integuments have been more or less extensively torn, ex- 
posing to the eye at once the naked bone, and thus removing all chance 
of error in the diagnosis. 

Norris mentions a case, seen by Hammersle.y, in which the astragalus 
was thrown completely out, and was subsequently found in the earth 



Fig. 351. 



Fig. 352. 





Simple dislocation of the astragalus outwards. 



Compound dislocation of the astragalus inwards. 



where the patient had received his injury. Inflammation, gangrene, 
and tetanus supervened, and the patient died on the seventh day. 1 

Prognosis. — It will be readily understood that nothing short of very 
great violence could disturb and completely break up the connections 
of a bone so compactly and firmly seated as is the astragalus, and that, 
aside of any unusual complications, under the most favorable circum- 
stances, intense inflammation must naturally be anticipated ; and, with 
few exceptions, this has actually taken place. Even when reduction 
has been promptly and easily effected, inflammation, gangrene, and death 
have sometimes speedily ensued. But more often the reduction has been 
found to be exceedingly difficult or impossible, and complete removal of 
the bone or amputation has been immediately demanded. 

In a limited number of cases, on the other hand, the bone has been 
easily reduced, and recovery has taken place, with a tolerably useful 
limb; or resection has been practised with an equally favorable result; 
in still other cases the bone has been left protruding, and the patient 
has finally recovered so far as to be able to walk again, but in such a 
crippled condition as to render the achievement a very doubtful triumph 
of conservative surgery. 



1 Norris, Amer. Journ. Med. Sci., 1837, p. 383. 



DISLOCATIONS OF THE ASTRAGALUS. 



847 



Norris, of Philadelphia, relates the following case, illustrating the 
imminent danger to which even the life of the patient may be exposed in 
those examples which are apparently the most simple. 

William Summerill, set. 30, was admitted to the Pennsylvania Hospi- 
tal on the 26th of September, 1831. An hour previous, while descend- 
ing a ladder, he slipped and fell in such a manner as to throw the entire 
weight of his body upon the outer part of his left foot. The foot was 
turned inwards, and nearly immovable ; a slight depression existed im- 
mediately below the lower end of the tibia, and there was a hard rounded 
projection on the outer part of the foot, a little below and in front of the 
extremity of the fibula; the skin over this projection was not broken or 
excoriated, but reddened ; there was no fracture of either bone of the leg. 

The symptoms rendered it plain that the astragalus was dislocated 
forwards and outwards. Dr. Barton, under whose care the patient was 
received, proceeded soon after to make attempts at reduction. The 
muscles of the leg were relaxed as much as possible, and extension made 
from the foot by seizing the heel and front part of the foot while an 
assistant made counter-extension at the knee. The bone was also pushed 
inwards toward the joint by the surgeon. These efforts were continued for 
a considerable time, but had no effect in changing the position of the bone. 

Six hours afterwards, Drs. Harris and Hewson being in consultation, 
the attempt was again made to accomplish the reduction, but without 
success; and the surgeons immediately proceeded to excise the bone. . 

An incision was made parallel with the tendons, commencing a short 
distance above the projection, and extending down far enough to expose 
fairly the astragalus and its torn ligaments. The bone was then seized 
with the forceps and easily removed after the division of a few liga- 
mentous fibres that continued to connect it with the adjoining parts. 
Very little bleeding occurred, only two small arteries requiring the 
ligature. 

After removal, it was discovered that about one-half of the surface 
which plays in the lower end of the tibia had been fractured, and that 
it remained firmly attached to the extremity of that bone. No attempt 
was made to remove this fragment ; but, the joint being carefully 
sponged out, the sides of the wound were brought together and closed 
by sutures, adhesive straps, and a roller ; after which the foot, placed 
in its natural position, was laid in a fracture-box. 

On the fifth day a slough began to form upon the outside of the foot, 
which was followed by suppuration at other points, and on the thirteenth 
day an opening was made to evacuate the pus near the malleolus in- 
ternus. At the end of about eight weeks the fragment of the astragalus 
which had been suffered to remain was found to be carious, and it was 
removed; the heel also had ulcerated from pressure, and several other 
bones of the tarsus were discovered to be carious. Fifteen months 
later, this poor fellow was still in the hospital, suffering from hectic, 
with extensive disease in the bones of the tarsus and ankle-joint. Fi- 
nally amputation of the leg was practised by Dr. Barton, a few days 
after which he died. 1 



1 Norris, Amer. Journ. Med. Sch, Aug. 1837, p. 378. 



848 TARSAL LUXATIONS. 

Norris mentions also two examples of simple dislocation of the as- 
tragalus at the Pennsylvania Hospital which came under the observa- 
tion of Dr. Barton, in both of which the bone was left unreduced. In 
one case inflammation and sloughing soon effected a complete exposure 
of the protruding bone, but after a time the skin cicatrized. At the 
end of five months the patient walked and had good use of the joint, 
though great deformity of the foot existed, and he continued to be 
subject to ulceration of the newly formed skin on its outer part. In 
the other case gangrene supervened soon after the accident, and the 
patient died. 

Norris adds that u the late Professor Wistar removed the astragalus 
in a case of compound dislocation, and the patient was cured with some 
motion at the joint." 

Dr. Alexander Stevens, of New York, made the same operation in 
a case of compound dislocation, and, after several months, he affirms 
that the patient " has recovered with very trifling deformity of the foot, 
and with a flexible joint. He walks with very slight lameness." 1 

I am indebted to Dr. B. II. Hart, of Marietta, Ohio, for an account 
of the following case, and for the specimen, which has, also, kindly 
been put in my possession. 

In June, 1853, Thomas Williams was thrown from his carriage, 
alighting upon his left foot and causing a compound dislocation of the 
ankle-joint. Dr. Hart was immediately called, and found the bones of 
the leg thrust through the integuments on the outside, the malleolus 
internus broken, and the astragalus partially dislocated. After enlarg- 
ing the opening in the integuments with a pocket-knife, the doctor was 
able to reduce the dislocated bones. It must be mentioned that this 
man weighed 225 lbs., and that in his fall he descended a precipice or 
bank 80 feet in height. Soon after the reduction the patient had two 
severe convulsions, which were arrested by bleeding and opiates, and 
never returned. Cool lotions were applied to the limb ; and on the 
sixth day erysipelas supervened and extended nearly to the body. The 
erysipelas continued about nine days. Extensive suppuration throughout 
the joint resulted, and some fragments of bone came away, and on the 
thirty-third day Dr. Hart removed, without the aid of the knife, the 
entire astragalus. In three months the patient walked upon crutches, 
and in eleven mont.hs he could walk well without a staff, a slight motion 
having been preserved in the ankle-joint. 

The dislocations backwards, of which I have found recorded only 
eight examples, have all, with but one exception, been left unreduced ; 
yet in at least five instances the patients have recovered with pretty 
useful limbs. Such was the fact with Liston's, Lizar's, and my own 
patients, and also with Mr. Phillips's two cases, to all of which I shall 
again refer. It must be noticed, however, that, in each of the cases 
mentioned as followed by a successful termination without reduction, the 
dislocations were simple. 

Turner, of Manchester, has reported one example of compound lux- 
ation outwards and backwards, in which, finding himself unable to 

1 Stevens, North Amer. Med. and Surg. Journ., Jan. 1827, p. 200. 



DISLOCATIONS OF THE ASTRAGALUS. 



849 



effect reduction, he removed the astragalus, with a tolerably successful 
result. 1 Finally, a case was presented in one of the London hospitals 
in 1839, of a dislocation inwards and backwards, which was reduced 
in about ten minutes, by extension accompanied with lateral pressure. 2 

In Sept. 1870, I saw, with Dr. Sayre, in consultation, a subluxation 
of the astragalus forwards and outwards, in the person of Mr. Stewart, 
of this city, which had just occurred in consequence of an injury re- 
ceived in being thrown from a carriage. The dislocation seemed to be 
nearly but not quite complete, causing great projection and tension of 
the skin. Under the influence of chlorofrom, by extension and pressure, 
it was easily reduced by Dr. Sayre. In five weeks from this time he 
was able to walk, and soon after the restoration of the functions of the 
joint was complete. 

Treatment. — Various attempts have been made by surgical writers to 
determine the line of treatment which should be adopted in these un- 
fortunate cases, but with very unsatisfactory results, since they are far 
from having arrived at similar conclusions, nor have they been able 
always to settle the question definitely for themselves. The difficulty 
consists in the multiplicity and lack of uniformity in the complications 
which attend these accidents, rendering it impossible to establish a classi- 
fication upon which a uniform treatment may be safely based. There 
are certain principles, however, which seem to be sufficiently settled to 
allow of an authoritative announcement ; these may be briefly stated as 
follows : If the dislocation is simple, reduce the astragalus immediately, 
provided this is possible. If the luxation is complete, and it cannot be 
reduced, even partially, proceed at once to resection or to amputation. 
In compound dislocations, resection or amputation affords the only safe 
resource. In all cases the inflammation is likely to be intense, in order 
to prevent which complication the surgeon must be unremitting in his 
use of the appropriate remedies. 

Out of eighteen cases of complete excision of the astragalus, collected 
by Turner, fourteen made good recoveries, and in only one of these 
fourteen was there anchylosis. 

The several indications and rules of treatment above enumerated we 
shall proceed to illustrate a little more fully. 

In a recent simple luxation of the astragalus forwards, the leg should 
be flexed to a right angle with the thigh, and, for the purpose of making 
extension, one assistant should take hold of the foot with both hands in 
the same manner that a servant draws a boot, that is, with the right 
hand grasping the heel, and the left placed upon the dorsum of the foot, 
near the toes. A second assistant should seize the lower part of the 
thigh, in order to make counter-extension, while the surgeon presses with 
the ball of his hand against the head of the astragalus, upwards and 
backwards. If these simple measures fail, the pulleys ought to be em- 
ployed as a substitute for the hands in making extension. In applying 



1 Turner, Trans. Provin. Med. and Surg. Journ., vol. ix. Essay on Disloc. of As 
trag., with nearly fifty cases. For additional cases, see Med. and Surg. Reporter, 
Jan. 1867. 

2 London Lancet, vol. ii. p. 559. 



850 TARSAL LUXATIONS. 

the extension, the toes must be kept well down, and occasionally the foot 
should be moved gently from one side to the other. 

An oblique dislocation must be reduced, if possible, to an anterior 
luxation, before an attempt is made to carry the head of the bone back 
to its place, as by this mode the reduction will be greatly facilitated. 

Lateral luxations may be reduced by the same means ; but if the 
astragalus is dislocated outwards, the foot must be held forcibly adducted 
during the extension ; and if it is dislocated inwards, the foot must be 
held strongly in the opposite direction. 

Lizars says that he has seen one case of backward luxation, and that 
all attempts at reduction were unavailing. The limb was, however, pre- 
served, and proved to be useful. 1 Liston was equally unsuccessful in a 
case which came under his notice. 2 Phillips has reported two cases, in 
neither of which was the reduction accomplished. 3 Nelaton has seen a 
compound dislocation which he could not reduce. 4 Mr. Erichsen, how- 
ever, who admits that when dislocated backwards it has not hitherto been 
reduced, declares that the surgeons at University Hospital have succeeded 
in one case recently, in which both the tibia and fibula were broken also. 5 
Mr. Erichsen suggests also that, in case of a failure by the ordinary 
means, we should resort to a subcutaneous section of the tendo A chillis. 
Mr. Williams, of Dublin, in a similar case, which had been left unre- 
duced, was obliged finally to extract the bone, in consequence of the in- 
teguments having sloughed. 6 

In February, 1875, Mr. J. N. Hall, of Colorado, jet. 88, consulted 
me in reference to an injury of his foot sustained two years before. The 
foot had been caught between a couple of timbers and violently twisted 
inwards. The nature of the accident was not at first recognized. I 
found the astragalus displaced backwards as far as the posterior ex- 
tremity of the calcaneura, causing the tendo Achillis to curve backwards; 
the astragalus was especially prominent on the inner side, posteriorly. 
The foot was at a right angle with the leg, and shortened in front three- 
eighths of an inch. The leg was shortened five-eighths of an inch. 
The foot was at times painful and numb. He walked very well with the 
aid of a cane. Of course, no surgical interference could be recommended. 

Compound dislocations, and such as are otherwise complicated, demand 
of the surgeon immediate amputation or exsection, the latter of which 
ought to be preferred whenever the condition of the limb encourages a 
reasonable hope that the foot may be saved. 

Dr. Grant, of Canada, has reported a case, however, of success after 
reduction of a compound dislocation of this bone. The man was 35 years 
old, and in good health. Immediately after the accident the astragalus was 
found completely dislocated forwards, and lying with its long axis placed 
transversely, so that the anterior extremity protruded through the integu- 

1 Lizars, System of Practical Surg., Edinburgh ed., 1847, p. 161. 

2 Liston, Elements of Surgery, vol. iii. p. 348. 

3 Phillips, Lond. Med. Graz., vol. xiv. p. 596. 

4 Nelaton, Pathologie Chirurg., t. ii. p. 482. 

5 Erichsen, Science and Art. of Surg., Amer. ed., 1859, p. 270. 

6 Williams, Erichsen, op. cit., p. 271. 



ASTKAGALO-CALCANEO-SCAPHOID DISLOCATIONS. 851 

ments one inch on the outer side of the foot. There was no fracture. 
The first attempt at reduction, by extension and pressure, failed ; but in 
the second attempt moderate pressure, without extension, was successful. 
Suppuration ensued, and continued two months. At the end of eight 
months he walked without a cane ; and at the date of the report the 
ankle was in all respects perfect. 1 

When exsection is practised, and the bone is found to be broken, as it 
often is, all the fragments should be carefully removed, since they are 
certain to become necrosed if left in place. Nor ought the surgeon to 
hesitate to lay open freely the tissues in every direction, in order that 
he may accomplish this purpose ; even the tendons lying over the pro- 
truding bone may be sacrificed unhesitatingly, since, after having been so 
severely bruised, stretched, and lacerated, they are pretty certain to 
slough. Indeed, the more freely the tissues are divided over the bone, 
the less will be the danger of inflammation, and the safer will be the life 
and limb of the patient. 

In addition to the examples already cited of compound dislocation in 
which the astragalus was removed, the following, reported by Dr. W. 
A. Gillespie, of Ellisville, Va., will also illustrate the occasional value 
of exsection in these severe accidents. 

Mrs. A., aged about 50 years, fell from a horse on the 23d of May, 
1833, dislocating both ankles. The luxation of the right foot was ac- 
companied with a luxation of the astragalus outwards, which projected 
through a very large wound in the integuments, and its trochlea was 
placed at an angle of about 45° with its natural position. Early on the 
following day it was removed by severing its few remaining connections, 
and the wound was immediately closed by stitches, adhesive plasters, and 
light dressings. From the moment of the receipt of the injury, and for 
several days afterwards, she suffered excruciating pain in the limb, and 
on the third day tetanus was apprehended, but its full accession was pre- 
vented by the free use of opiates. The limb was suspended in N. R. 
Smith's fracture-apparatus ; and as gangrene with hectic fever soon 
threatened the life of the patient, fermenting poultices were diligently 
applied, and the patient was sustained by wine, bark, and other tonics. 
Two months after the injury was received, the date at which the report 
is given, the wound had entirely healed, and her complete recovery was 
regarded as certain. 2 Many other similar examples have been reported 
by foreign surgeons. 

§ 2. Astragalo-Calcaneo-Scaphoid Dislocations. 

It is perhaps quite as common for the astragalus to be dislocated from 
the scaphoid bone and calcaneum, while it retains its connections with 
the tibia, as to be luxated from all these bones at the same time. This 
astragalo-calcaneo-scaphoicl dislocation is that which Malgaigne has 
termed " subastragaloid." Produced by the same causes which deter- 

1 Grant, Canada Med. Journ., Oct. 1865. 

2 Gillespie, Amer. Journ. Med. Sci., Aug. 1833, p. 552. 



852 TARSAL LUXATIONS. 

mine true dislocations of the astragalus, it may occur in the same direc- 
tions, and is liable to the same complications ; nor will either the prog- 
nosis or treatment differ essentially from that which is recognized and 
established in the other accident. 

As in dislocations proper of the astragalus, so also in this accident, 
opposite results have occasionally followed from similar modes of treat- 
ment. Thus, Dr. Detmold, of New York, stated in 1856 to the New 
York Academy of Medicine, that he had recently met with a dislocation 
of the astragalus, in which the bone retained its proper relations with 
the tibia, but not with the bones of the tarsus. The patient had fallen 
from a wagon and caught his foot in the wheel. Dr. Detmold made ex- 
tension with pulleys, but could not effect the reduction. Subsequently 
he was obliged to remove the astragalus on account of the suppuration 
which followed and the consequent exposure of the bone. The wound 
did not heal kindly, and at length amputation of the leg became neces- 
sary. 

Dr. Detmold concludes, from this example and others which have 
come to his knowledge, that if a similar case were to present itself to 
him again, he would amputate at once. 1 

The following case, reported by Dr. Thomas Wells, of Columbia, S. 
C, is of unusual interest, as illustrating the danger of leaving the bone 
displaced, and also the benefit which may, even under the most unfavor- 
able circumstances, result from its final removal. 

Dr. S., set. 30, was riding in an open carriage, some time during the 
year 1819, when his horses became frightened and ran, and in leaping 
from his vehicle he struck upon his left foot, dislocating the astragalus 
from its junction with the scaphoid bone, upwards and slightly outwards. 
Several medical gentlemen made violent efforts to reduce the bone, but 
without effect. Inflammation and suppuration, accompanied by a high 
fever, soon followed, and the head of the astragalus, becoming carious, 
protruded through the skin. On the 18th of August, about seven months 
after the injury was received, he was still suffering from a copious dis- 
charge, pain, swelling, and general irritative fever, and it was deter- 
mined to excise the bone ; which was accordingly done by enlarging 
the wound and detaching its loose connections with the adjacent tissues. 
The astragalus extracted left a frightful wound, the foot seeming to be 
nearly separated from the leg. A hollow splint was adjusted to the 
inside of the foot and leg, so as to preserve the limb perfectly steady 
and in a proper direction ; simple dressings were applied, and an anodyne 
administered internally. No accidents followed, and at the end of Sep- 
tember the wound was healed, and the swelling of the parts had entirely 
subsided. One year after the operation, he walked without the least 
difficulty ; the ankle being then " perfectly sound." The leg was short- 
ened about one inch, and this deficiency was supplied by a thick heel 
upon his shoe. 2 

Examples might be cited illustrative of the value of early exsection 

1 Detmold, New York Journ. Med., May, 1856, p. 383. 

2 Wells, Amer. Journ. Med. S'ci., May, 1832, p. 21. 



DISLOCATIONS OF THE CALCANEUM. 853 

where reduction could not be accomplished ; but, after what has already 
been said upon the subject of dislocations of the astragalus, we shall not 
regard any farther reference as either necessary or useful. If other 
principles of treatment are to govern the surgeon than those which we 
have already laid down, they cannot here be stated. They are among 
those unwritten rules whose existence we cannot always recognize until 
the case arises upon which they may apply. Yet, in the exigency sup- 
posed, they are as clearly defined, and as imperative, in the mind of the 
clever surgeon, as any of those laws which have been made the subjects 
of special record. 

§ 3. Dislocations of the Calcaneum. 

The calcaneum may, as a consequence of a fall upon the heel, or of 
a direct blow, be dislocated outwards from the astragalus alone, or up- 
wards and outwards from the cuboid bone at the same time. It has 
been found also at the same moment dislocated outwards from the 
astragalus and inwards upon the cuboid bone. 

Chelius says he has seen an old dislocation of the calcaneum, pro- 
duced in early life by pulling off a boot, from which there finally resulted 
a degeneration like elephantiasis of the leg, rendering amputation neces- 
sary. 1 

Mr. South remarks, in his Notes to Chelius, that the two cases of 
dislocation outwards of this bone, mentioned by Sir Astley Cooper, 
were from his (South's) Notes (cases 199 and 200). In the first case, 
that of Martin Bentley, occasioned by the falling of a heavy stone upon 
his foot, the integuments were not broken, and the position of the foot 
resembled a varus. "The dislocation was easily reduced, having bent 
the thigh and knee on the body and fixed the leg, by laying hold of the 
metatarsus and of the tuberosity of the heel-bone, and drawing the foot 
gently and directly from the leg, during which extension Cline put his 
knee against the outside of the joint, and the foot being pressed against 
it, the heel and the navicular bone readily slipped into their place, and 
the deformity disappeared." He was discharged from the hospital in 
five weeks, " having the complete use of his foot." 

In the second case, the dislocation, produced also by the fall of a 
stone upon the foot, was compound, and the patient, Thomas Gilmore, 
having been brought into St. Thomas's Hospital, the reduction was 
effected by extending the foot and rotating it outwards. Six months 
after, when he left the hospital, he was able to walk pretty well with a 
stick. 

§ 4. Middle Tarsal Dislocations. 

The scaphoid and cuboid bones may be dislocated from the astragalus 
and calcaneum, constituting what is termed, by Malgaigne, a " middle tar- 
sal" dislocation. It is probable that, to some extent, the same thing has 
occurred in many of these cases which are reported as simple dislocations 

1 Chelius, System of Surg., Amer. ed., vol. ii. p. 354. 



854 TARSAL LUXATIONS. 

of the astragalus, or as dislocations at the astragalo-scaphoid articulation ; 
but it occurs also occasionally in a degree so perfect and complete as to 
leave no doubt as to the true nature of the disjunction, and to entitle it 
to a separate consideration. 

Mr. Liston mentions a case of a boy, set. 14, who fell from a height 
of forty feet, striking, apparently, upon the extremity of the foot. The 
scaphoid and cuboid bones were found to be displaced upwards and for- 
wards, so that the foot was shortened about half an inch, and had a 
clubbed appearance. No attempt was made to reduce the bones, and he 
left the hospital in three weeks, able to stand on the foot. 1 

Sir Astley Cooper has recorded in more detail a similar example. A 
man, working at the Southwark bridge, London, received upon the top 
of his foot a stone of great weight. He was immediately carried to 
Guy's Hospital, and his condition is described as follows : " The os calcis 
and the astragalus remained in their natural situations, but the forepart 
of the foot was turned inwards upon the bones. When examined by 
the students, the appearance was so precisely like that of a club-foot, 
that they could not at first believe but that it was a natural defect of 
that kind;" but, upon the assurance of the man that previous to the acci- 
dent his foot was not distorted, extension was made, and the reduction 
was effected. He was discharged from the hospital in five weeks, having 
the complete use of his foot. 2 

§ 5. Dislocations of the Cuboid Bones. 

According to Pie'dagnel, quoted by Chelius, the cuboid bone may be 
dislocated upwards, inwards, and downwards, but Malgaigne affirms that 
he has found no. case recorded in which the dislocation has occurred 
alone, or unaccompanied with a dislocation of one or more of the other 
tarsal bones. 

§ 6. Dislocations of the Scaphoid Bones. 

Burnett has seen a luxation of the scaphoid bone in which its connec- 
tions with the astragalus were undisturbed, while at the same time it was 
completely separated from the cuneiform bones. By strong pressure 
exercised during several minutes, the os scaphoides was made to fall, into 
its place. The dislocation was compound, yet the wound healed rapidly, 
and in a short time the recovery was almost complete. 3 

Several examples are recorded of a true luxation of the os scaphoides, 
in which the bone had abandoned both the astragalus on the one hand, 
and the cuneiform bones on the other. 

Pi^dagnel mentions a case in which the scaphoid bone was broken lon- 
gitudinally, and its internal fragment, constituting the largest portion, 
was displaced inwards through a tegumentary wound. He was unable 
to effect reduction, and was compelled to amputate the foot. 4 

1 Practical Surgery ; also London Lancet, vol. xxxvii. p. 133. 

2 Sir A. Cooper on Disloc, etc., London ed., 1823, p. 376. 

3 Burnett, Lond. Med. Gazette, 1837, vol. xix. p. 221. 

4 Piedagnel, Journ. Univ. et Heb., torn. ii. p. 208. 



DISLOCATIONS OF THE CUNEIFORM BONES. 855 

Walker has reported the first example of luxation forwards, occasioned 
by jumping upon the ball of the foot. The bone formed a marked pro- 
jection upon the top of the foot, and a corresponding depression existed 
below. An attempt was first made to accomplish the reduction by sim- 
ple pressure with the thumbs ; but this having failed, the surgeon bent 
the extremity of the foot forcibly downwards, and by continuing to press 
upon the os scaphoides, it fell into its position easily and with a distinct 
click. In about three weeks the patient was able to walk with only a 
slight halt, and no deformity remained. 1 

§ 7. Dislocations of the Cuneiform Bones. 

The cuneiform bones may be luxated partially, and without having 
separated from each other, of which two or three examples are recorded ; 
or, which is more common, the internal cuneiform may be luxated 
alone. Says Sir Astley Cooper : " I have twice seen this bone dislo- 
cated ; once in a gentleman who called upon me some weeks after the 
accident, and a second time in a case which occurred in Guy's Hospital 
very lately. In both instances the same appearances presented them- 
selves. There was a great projection of the bone inwards, and some 
degree of elevation, from its being drawn up by the action of the tibialis 
anticus muscle ; and it no longer remained in a direct line with the meta- 
tarsal bone of the great toe. In neither case was the bone reduced. The 
subject of the first of these accidents walked with but little halting, and 
I believe would in time recover the use of the foot, so as not to appear 
lame. The cause of the accident was a fall from a considerable height, 
by which the ligament was ruptured which connects this bone with the 
os cuneiforme, and with the os naviculare. The second case, which was 
in Guy's Hospital, my apprentice, Mr. Babington, informs me, happened 
by the fall of a horse, and the foot was caught between the horse and 
the curbstone." 2 

In a case of compound luxation seen by Mr. Key, reduction was 
effected, and in two months the cure was so far completed that the 
patient walked with only a slight lameness. 3 Xelaton, in a similar 
case of compound luxation, unable to reduce the bone, removed it com- 
pletely, and the patient recovered. 4 

Robert Smith has called attention to a species of dislocation of the 
internal cuneiform bone not before very accurately described ; but of 
which he has presented two examples. It consists in simultaneous dis- 
location of the metatarsus and internal cuneiform ; that is to say, the 
first metatarsal bone, together with the internal cuneiform, is dislocated 
upwards and backwards upon the tarsus, carrying with it also the four 
remaining metatarsal bones. In both of the examples seen and recorded 
by him, the dislocations were ancient, and no account could be obtained 
of the precise manner in which the accidents had been produced. The 

' Walker, The Medical Examiner, 1851, p. 203. 

2 Sir Astley Cooper, op. cit., p. 383. 

3 Key, Gkiy's Hosp. Rep., 1836, vol. i. p. 544. 

4 Nelaton, Malgaigne, op. cit., p. 1076. 



856 TARSAL LUXATIONS. 

feet were foreshortened to the extent of an inch or more, in consequence 
of the overlapping of the bones, yet the heel in each case preserved its 
natural relations to the tibia, not being proportionately lengthened as 
is the case in dislocations of the tibia forwards. The plantar surface of 
the foot was turned inwards, and instead of being concave it was convex, 
both in its antero-posterior and transverse diameters. A transverse 
ridge on the top of the foot also indicated the line of the projecting 
bones. Both of these cases were verified by a careful dissection. 1 

Dupuytren has reported in his Treatise on Injuries of the Bones, a 
similar case, occurring in a woman, get. 30, who was brought immedi- 
ately to Hotel Dieu. She stated that in descending from the bridge of 
St. Michael, with a burden of two hundred pounds, she fell in such a 
way that the whole weight of the body was received on the right foot, 
and that, at the moment she made an effort to check herself in falling, 
she experienced extremely severe pain in this part, and heard a very 
distinct snap ; she was unable to raise herself from the ground. On the 
following morning Dupuytren reduced the bones with very little diffi- 
culty by extension, combined with pressure against the dislocated ends. 
The bones went into place with a loud snap, and in two or three months 
she left the hospital, with only a little lameness. 2 

Mr. Smith, without intending to question the possibility of a simple 
luxation of the metatarsal bones, of which, indeed, Malgaigne has col- 
lected a number of well-authenticated examples, is inclined to believe 
that, when a luxation of the bones of the metatarsus is the consequence 
of a fall from a height, the individual alighting upon the anterior part 
of the foot, it is, in general, that variety which has now been described. 
And this aptness on the part of the cuneiform bone to maintain its con- 
nection with the first metatarsal bone, he would ascribe mainly to the 
fact that both the peroneus longus and tibialis anticus have attachments 
to each of the bones in question. 

1 Robert Smith, Treatise on Fractures, etc., Dublin ed., 1854, p. 224 et seq. 

2 Dupuytren, op. cit. p. 326. 



DISLOCATIONS OF THE METATARSAL BOXES. 857 



CHAPTER XXIII. 

DISLOCATIONS OF THE METATARSAL BONES. 

Luxations of one or more of the metatarsal bones, at the points of 
their articulations with the tarsus, have been known to occur in almost 
every direction. They may be occasioned by crushing accidents, by 
machinery, or more often perhaps they have been caused by a fall back- 
wards or forwards, when the anterior extremity of the foot was wedged 
under some solid body and immovably fixed. They may be produced 
also, probably, by simply striking upon the ball of the foot in falling 
from a height. We have noticed, however, that Mr. Robert Smith in- 
clines to the opinion that this will, in general, only produce the species 
of dislocation which he has particularly described. 

The symptoms which characterize the dislocation of the whole range 
of metatarsal bones upwards and backwards will, when the dislocation 
is complete, resemble very much those which belong to the dislocation 
described by Smith. The dorsum of the foot will be shortened antero- 
posterior^, the two arches of the foot will be lost upon the plantar sur- 
face, or even actually reversed, a ridge will traverse the back of the 
foot and a corresponding depression will exist underneath. 

In some cases, however, the dislocation is not complete, the articula- 
tions being only sprung, and then there can exist no foreshortening of 
the foot, and all the other signs will be less striking. 

If only a single bone is luxated the diagnosis is generally very easily 
made out, unless, indeed, considerable swelling has already occurred. 

Mr. South says that, in 1835, a case was admitted to St. Thomas's 
Hospital, under Mr. Green's care, of dislocation of the last two metatar- 
sal bones, occasioned by the falling of a heavy chest upon the inside of 
the foot. Upon the top of the foot was a large swelling below and in 
front of the outer ankle, and behind it a cavity in which two fingers 
could be easily buried, in consequence of the bases of the metatarsal 
bones having been thrown upwards and backwards upon the top of the 
cuboid bone. The reduction was accomplished with much difficulty by 
continued extension, and as the bones resumed their place a distinct 
crackling was heard. 1 

Listen reduced a dislocation upwards of the first metatarsal bone. 
Malgaigne mistook a dislocation of the fourth bone for a fracture, and 
did not attempt the reduction until the seventh day, when, after five 
successive trials, the head entered with a noise into its cavity. In a 
dislocation of the second, third, and fourth metatarsal bones, he also 
failed to detect the true nature of the accident until the tenth day, 

1 South, Note to Chelius's Surg., vol. ii. p. 256. 
55 



858 DISLOCATIONS OF THE METATARSAL BONES. 

when he proceeded to attempt reduction, but failed. Inflammation, 
suppuration, and delirium followed, and the patient died on the forty- 
first clay. Tufnell failed in a similar case, although his patient finally 
recovered with a not very useful limb. Malgaigne failed to reduce the 
bones also in a recent case of luxation of the first four bones, although 
he used chloroform and diligently tried various means. The same 
writer has seen one example of ancient dislocation, which was not re- 
cognized by the surgeon. Finally, Monteggia reports a case of disloca- 
tion of the last two metatarsal bones, which was not at the time recognized. 
On the tenth day swelling commenced, and soon after the patient died in 
convulsions. 1 

These references, drawn chiefly from Malgaigne, sufficiently illustrate 
the difficulty which surgeons have experienced in the reduction of these 
bones, when a portion only is displaced. A difficulty which is probably 
due to the fact that it is almost impossible to make extension upon a 
single metatarsal bone ; indeed, it is probable that by pressure only upon 
the displaced head can we expect to accomplish much in these accidents, 
and even this cannot be made to act very effectively, owing to the small 
amount of surface presented against which the force can be properly 
applied. 

If, on the other hand, all the bones are dislocated at once, the reduc- 
tion is generally accomplished with ease by simple extension, combined 
with properly directed pressure. Bouchard and Meynier succeeded with- 
out difficulty in two cases of backward dislocation ; Smyly was equally 
successful on the sixth day, in a case of dislocation downwards. Laugier 
reduced an outward dislocation of all the bones by pressure and exten- 
sion easily; and Kirk succeeded as well, in an example of the opposite 
character, all the bones being carried inwards. 2 

Mr. Sandwith has given us an account of a case which occurred in 
his own person, from the fall of his horse upon his foot. " I was in- 
stantly sensible," says Mr. Sandwith, " of the nature of the injury, and 
as soon as I was upon my feet, the metatarsus was found to be drawn 
upwards, and obliquely outwards upon the tarsus, by the action of the 
flexor muscles. On the removal of the boot, which was cut away, these 
were the appearances: The foot considerably shortened, the toes turned 
a little outwards, and a hard swelling, bigger than an egg, upon the 
tarsus, with tumefaction of the integuments. The pain, which was great 
at first, was kept under by a warm fomentation. 

" The reduction was easily effected by my friends Messrs. Williams 
and Brereton, and leeches and bread-and-water poultices prevented in- 
flammation. For several nights the foot was violently shaken by spas- 
modic action of the muscles, but the. parts preserved their relative situa- 
tion ; and, although it was nearly a year before all lameness ceased, yet 
at the end of six weeks I was enabled to lay aside my crutches. For 
the ability to use the foot in so short a time, I was indebted to a con- 
trivance which rendered the foot and ankle inflexible. 

" Instead of an elastic sole to the shoe part of the apparatus, one of 
wood was procured, around the heel of which was nailed a piece of firm, 

1 Malgaigne, op. cit., p. 1077 et seq. 2 Ibid., op. cit., p. 1081. 



DISLOCATIONS OF THE PHALANGES OF THE TOES. 859 

unbending leather ; this reached as high as the calf of the leg ; three 
small straps with buckles held the leg in situ, and a broader one across 
the instep secured the foot. The comfort I experienced from this simple 
apparatus is my reason for describing it so particularly ; it has since been 
found useful in various injuries of the foot and ankle." 1 

In one extraordinary case, however, Dupuytren was not so successful. 
Paul Eudes, get. 24, fell, while drunk, into a ditch six feet deep, and 
alighted on the soles of his feet. The accident was followed by great 
swelling, and he did not suspect the nature of the injury, nor present 
himself at the hospital until three weeks after. Dupuytren then ascer- 
tained that he had dislocated the metatarsal bones of both feet. Several 
fruitless attempts were made to accomplish the reduction, but to no pur- 
pose, and in about two weeks he left the hospital. 2 



CHAPTEE XXIY. 

DISLOCATIONS OF THE PHALANGES OF THE TOES. 

Dislocations of the toes are less common than those of the fingers, 
yet a considerable number of cases have been recorded by different sur- 
geons. They are occasioned by blows received directly upon the ends 
of the toes ; by the weight of the body brought to bear suddenly upon 
their plantar surfaces, as when a horseman springs in his stirrups, or by 
a fall, in consequence of which the rider hangs in his stirrup ; by leap- 
ing, etc. 

They may be partial or complete ; and in the latter case, a slight over- 
lapping is generally observed. In a great majority of cases the direc- 
tion of the displacement is backwards, or with only a slight lateral devi- 
ation. Occasionally several bones are displaced at the same time, but 
usually only one surfers displacement. It is more common here to find 
compound and complicated dislocations than in the case of the fingers. 

The position of the toes is not always the same in the same form of 
dislocations. Thus, in the dislocation backwards, the toe is sometimes 
reversed upon the foot to nearly a right angle, and at other times it is 
found lying in the same axis as the metatarsal bone, or the phalanx, 
from which it is luxated. Some years since I reduced a backward 
dislocation of the first phalanx of the second toe in the person of Lewis 
Britton, jet. 60, who had fallen from a fourth-story window, striking 
upon his feet, and breaking both thighs. I did not discover the dislo- 
cation of the toe until sixteen hours after the accident. It was then 
lying parallel with the axis of the metatarsal bone, upon which it was 
slightly overlapped. The reduction was effected easily by pulling upon 



1 Sandwith, Amer. Journ. Med. Sci., Nov. 1828, p. 216 ; from Loud. Med. Gaz. 
vol. i. 

2 Dupuytren, op. cit., p. 329. 



860 COMPOUND DISLOCATIONS OF THE LONG BONES. 

the last phalanx with my fingers, while at the same moment I pushed the 
head of the bone toward the socket. No swelling followed, nor has it 
troubled him at all since his recovery. 

Dr. John H. Packard, of Philadelphia, informs me that in a disloca- 
tion backwards of the first phalanx of the great toe, occurring in a Very 
muscular man, the phalanges were found lying parallel with the meta- 
tarsal bone ; and it was reduced easily by extension, while the patient 
was under the influence of ether. 

Treatment. — With regard to the treatment, surgeons have experienced 
the same difficulty, in certain cases of dislocation of the great toe, as we 
have seen experienced in similar dislocations of the thumb. Occasionally, 
indeed, the reduction has been found to be impossible. The same doubts 
have existed also in relation to the causes of this difficulty, and in refer- 
ence to the means by which it was to be overcome. We shall therefore 
refer the reader to the chapter on Dislocations of the First Phalanges of 
the Thumb and Fingers, for a more full consideration of this matter. 

In case the smaller toes are luxated, the reduction is generally effected 
with ease, by simple extension, or by extension combined with pressure ; 
sometimes, also, the bone will be more easily put in place by reversing 
the phalanx more completely, as we have advised in certain cases of 
dislocations of the fingers. 

If the skin is penetrated, it will often be found necessary either to 
amputate or to practise resection upon the exposed phalanx. 

Sir Astley Cooper relates a case of luxation of " all the smaller toes," 
from the metatarsus, which had not been reduced, and the subject of 
which was, in consequence, so much maimed that he was unable to labor. 
It had been occasioned by a fall, from a considerable height, upon the 
extremities of the toes. A projection existed at the roots of all the 
smaller toes, the extremity of each metatarsal bone being placed under 
the first phalanx of its corresponding toe. The swelling which imme- 
diately followed the receipt of the injury had concealed its nature, and 
now, several months having elapsed, reduction could not be effected. 
The only relief which could be afforded him, therefore, was in wearing 
a piece of hollow cork at the bottom of the inner part of the shoe, to 
prevent the pressure of the metarsal bones upon the nerves and 
bloodvessels. 1 



CHAPTEE XXY. 

COMPOUND DISLOCATIONS OF THE LONG BONES. 

Frequency of Compound as compared with Simple Dislocations. — 
Compound dislocations, as compared with simple, are of rare occurrence. 
Of ninety-four dislocations reported by Norris as having been received 
into the Pennsylvania Hospital for the ten years ending in 1840, only 



1 Sir Astley Cooper, op. cit., p. 385. 



COMPOUND DISLOCATIONS OF THE LONG BOXES. 861 

two were compound ;* and of one hundred and sixty-six dislocations in my 
record of personal observation made in 1855, only eight were compound. 2 

Relative Frequency in the Different Joints. — In my own recorded cases 
just referred to, four were dislocations of the tibia inwards at the ankle- 
joint, one was a partial (pathological) luxation forwards at the same joint, 
one a luxation of the astragalus, one a luxation of the head of the humerus 
into the axilla, and one a forward luxation of the radius and ulna at the 
wrist-joint. I have also met with several examples of compound dislo- 
cations of the fingers. Both of the cases reported by Norris were 
dislocations of the thumb. 

Sir Astley Cooper, speaking upon this point, says that the elbow, 
wrist, ankle, and finger-joints are most subject to these accidents ; and 
that he has seen but two in the shoulder-joint, and one in the knee-joint. 
He had never seen a compound dislocation at the hip-joint, and he 
believed that it was " scarcely ever" so dislocated. Mr. Bransby 
Cooper has, however, reported in detail a very interesting case of this 
accident, communicated to him by Dr. Walker, of Charlestown, Mass., 
in which reduction was accomplished by manipulation alone, by Dr. 
Ingalls on the second day. The patient died at the end of about three 
weeks. 3 So far as I know, this is the only case upon record. Mal- 
gaigne says that a compound dislocation at the hip-joint has probably 
never occurred. 

Among the cases of compound dislocation recorded by Sir Astley and 
Bransby Cooper, most of which were communicated to these gentlemen 
by other surgeons, forty-five were dislocations of the ankle, ten of the 
astragalus, four of the ulna at the wrist-joint, four of the thumb, two of 
the knee, one of the shoulder, one of the elbow, one of the radius and 
ulna at the wrist, one of the scaphoid bone, and one of the metatarsal 
bone of the great toe. Other writers have occasionally described com- 
pound dislocations of the clavicle, but I know of no record of a compound 
dislocation of the lower jaw. 

Prognosis, as determined by the Mode of Treatment adopted by most 
of the Ancient and many of the Modern Surgeons. — By most of the 
early writers these accidents, whenever they occurred in the larger joints, 
were regarded as nearly beyond the reach of art. Says Hippocrates : 
" In cases of complete dislocation at the ankle-joint, complicated with 
an external wound, whether the displacement be inwards or outwards, 
you are not to reduce the parts, but let any other physician reduce them 
if he choose. For this you should know for certain, that the patient 
will die if the parts are allowed to remain reduced, and that he will not 
survive more than a few days, for few of them pass the seventh day, 
being cut off by convulsions, and sometimes the leg and foot are seized 
with gangrene." Hippocrates adds : " But if not reduced, nor any 
attempt at first made to reduce them, most of such cases recover." 4 

1 Norris, Amer. Journ. Med. Sci., April, 1841, p. 335. 

2 For most of these cases, see Transactions of the New York State Med. Soc. for 
1855, article entitled " Report on Dislocations, with especial reference to their 
Results," by F. H. Hamilton. 

3 A. Cooper, on Dislocations, etc., by B. Cooper, p. 59. 

4 Works of Hippocrates, Sydenham ed., London, vol. ii. p. 634. 



862 COMPOUND DISLOCATIONS OF THE LONG BONES. 

The same remarks are applied by Hippocrates to compound disloca- 
tions of the head of the tibia, of the lower end of the femur, of the 
wrist, elbow, and shoulder-joints ; death occurring in all cases, as he be- 
lieves, more or less speedily whenever the bones are reduced and retained 
in place a sufficient length of time, and " were it not that the physician 
would be exposed to censure," he would not reduce even the bones of 
the fingers, since it must be expected, he thinks, that their articular ex- 
tremities will exfoliate even when the reduction is most successful. 

I shall presently show, however, that even Hippocrates advised and 
probably practised resection in certain cases of these accidents. 

Both Celsus and Galen adopt almost without qualification the line of 
practice laid down by Hippocrates, and affirm equally the danger and 
almost certain death consequent upon the reduction of compound dislo- 
cations in large joints. 1 Celsus recommends resection in some cases. 

Paulus iEgineta, however, and after him Albucasis, Haly Abbas, and 
Bhazes, do not regard the rules established by Hippocrates, in relation 
to the non-reduction of the bones, as so imperative, nor the results of the 
opposite practice as so uniformly fatal. 

" Hippocrates remarks," says Paulus iEgineta, " in the case of dislo- 
cations with a wound, the utmost discretion is required. For these, if 
reduced, occasion the most imminent danger, and sometimes death, the 
surrounding nerves and muscles being inflamed by the extension, so that 
strong pains, spasms, and acute fevers are produced, more particularly 
in the case of the elbows, knees, and joints above, for the nearer they 
are to the vital parts the greater is the danger they induce. Wherefore, 
Hippocrates, by all means, forbids us to apply reduction and strong band- 
aging to them, and directs us to use only anti-inflammatory and soothing 
applications to them at the commencement, for that by this treatment life 
may sometimes be preserved. But what he recommends for the fingers 
alone, we would attempt to do for all the other joints ; at first and while 
the parts remain free from inflammation, we Avould reduce the dislocated 
•joint by moderate extension, and if we succeed in our object, we may 
persist in using the anti-inflammatory treatment only. But if inflamma- 
tion, spasm, or any of the aforementioned symptoms come on, we must 
dislocate it again if it can be done without violence. If, however, we 
are apprehensive of this danger (for perhaps, if inflammation should 
come on, it will not yield), it will be better to defer the reduction of the 
greater joints at the commencement ; and when the inflammation sub- 
sides, which happens about the seventh or ninth day, then, having fore- 
told the danger from reduction, and explained how, if not reduced, they 
will be mutilated for life, we may try to make the attempt without vio- 
lence, using also the lever to facilitate the process." 2 

In the following quotations from three of the most celebrated writers 
of the last two centuries, we find but little if any evidence that the opin- 
ions of the fathers upon this subject were not still held in general re- 
spect : " If the joint be dislocated, so that it is either uncovered, or a 
little thrust forth without the skin, the accident is mortal, and of more 
danger to be reduced than if it be not reduced. For if it be not reduced, 

« Paulus iEgineta, Syd. ed., vol. ii. p. 510. 2 ibid., p . 509. 



COMPOUND DISLOCATIONS OF THE LONG BONES. 863 

inflammation will come upon it, convulsion, and sometimes death. 2. 
There will be a filthiness of the part itself. 3. An incurable ulcer, and 
if perhaps it be brought to cicatrize at all, it will easily be dissolved by 
reason of the softness of it ; but if it be reduced, it brings extreme dan- 
ger of convulsion, gangrene, and death." 1 

u Si vero in magnis articulis tarn valida fuit facta luxatio, ut liga- 
mentis ruptis os articuli multum sit protrusum per integumenta, haec 
pars ossis vasis privata moritur, citius autum si reponatur, quam si non 
reponitur ; quare sola amputatio restat ad conservationem vitge." 2 

Heister, who makes no allusion to this subject in the first edition of 
his great work, published at Amsterdam in 1739, adds the following 
remarks in his last edition, translated and published in London in 1768: 
" Dislocations attended with a wound, especially of the shoulder or thigh- 
bone, are of very bad consequence, and often endanger the life of the 
patient; in Celsus's opinion (Book VIII., Chap. XXV.), whether the 
bones be replaced or not, there is generally great clanger ; and so much 
the more the nearer the wound is to the joint. Hippocrates has declared 
that no bones can be reduced with security, beside those of the hands 
and feet. (Vectiar. 19, 5.) See more on this subject in that passage of 
Celsus just now quoted, though I by no means recommend the following 
him implicitly.'* 3 

Such were the extreme views as to the fatality of these accidents, and 
of the feebleness of our resources, entertained by the ancient, and even 
by the more modern writers almost down to our own day ; with only rare 
exceptions these limbs were condemned either to great and inevitable de- 
formity, or to amputation. Nor, if we speak only of their fatality, have 
surgeons ceased to regard these accidents as among the most grave with 
which they have to deal. 

Pathology and Appreciation of the Sources of Danger as compared 
especially ivitli Compound Fractures. — The danger, according to Sir 
Astley Cooper, consists in the rapid inflammation of the synovial mem- 
branes, which is speedily followed by suppuration and ulceration, where- 
by the ends of the bones become exposed ; and for the repair of which 
lesions great general as well as local efforts are required, and a high de- 
gree of constitutional irritation results. In addition to which circum- 
stances, " the violence inflicted on the neighboring parts, the injury of 
the muscles and tendons, and the laceration of bloodvessels, necessarily 
lead to more important and dangerous consequences than those which 
follow simple dislocations." 

The sources of danger enumerated by Sir Astley Cooper have been 
regarded as sufficient to account for their extraordinary fatality by the 
majority of those modern surgical writers who have alluded to the sub- 
ject ; but I must confess that to me they do not appear so. In compound 
fractures the mortality is far less ; yet one might naturally suppose, that 
when the sharp and irregular fragments are pressing into the flesh, among 

1 Chirurgeon's Storehouse. By Johannes Scultetus, of Ulme, in Suevia. London 
eel., 1674, p. 31. 

2 Johannes de Grorter. Chirurgia repurgata. Lugduni Batavorem, 1742, p. 86. 

3 General System of Surgery, by Dr. Laurence Heister. 8th ed. London, 1768, 
vol. i. p. 164. 



864 COMPOUND DISLOCATIONS OF THE LONG BONES. 

nerves and "bloodvessels, the irritation and inflammation would be equal, 
if not more than equal, to the irritation and consequent inflammation 
produced by exposing a joint surface to the air ; indeed, modern expe- 
rience has sufficiently shown that these surfaces are much more tolerant 
of atmospheric exposure, and of the action of many other irritants, than 
surgeons formerly supposed. A clean incision into a large joint, which 
exposes the synovial membranes to the air, and which permits the pro- 
ducts of inflammation to escape freely, is attended with much less danger 
than a small puncture which does not at all permit the air to enter, nor 
the increased synovia and the pus to escape. Very grave results some- 
times follow from large wounds into large joints, but under judicious 
treatment such results are the exception and not the rule. 1 But Sir 
Astley evidently attributes more of the bad consequences to the exhaust- 
ing effects of the efforts at repair, than to the immediate inflammation 
resulting from the exposure of the joint. It is pretty certain, however, 
that a majority of these patients die at a period too early to render this 
cause in any considerable degree operative. 

As to the bruising of the " muscles and tendons, and laceration of 
bloodvessels," it cannot be denied that it must usually be greater than 
in " simple dislocations ;" and I will not say that it is not in a given 
number of instances greater than in the same number of instances of 
compound fractures. The tissues have often been thrust rudely through 
by a large and smooth bone, and the tendons have been stretched vio- 
lently or torn completely asunder ; while occasionally large arteries, 
which are prone to hug the bones about the joints, are lacerated and 
left to bleed. That the importance of these complications, however, 
may not be overestimated, we must state that Sir Astley Cooper himself 
has remarked how seldom, in compound dislocations of the ankle-joint, 
the large arteries are injured ; that a tearing of the ligaments and of the 
tendons is almost as likely to occur in simple dislocations as in compound ; 
and, indeed, that in neither case are the tendons usually ruptured, but 
only thrust aside. Moreover, the skin is often made to give way not so 
much from the pressure of the round head within, as from the equal 
pressure of some sharp angular body from without. In all these respects, 
there are many examples of compound fractures which possess not a whit 
of advantage ; in which cases, nevertheless, the surgeon feels very little 
doubt as to the ultimate cure. 

In short, the causes which, according to Sir Astley Cooper, determine 
the extraordinary fatality of these accidents, do not sufficiently differ 
from those which operate in compound fractures to occasion so great a 
difference in results, and the fatality of compound dislocations remains 
unexplained ; or if surgical writers have here and there intimated the 
true cause, they have failed to give it its proper place and value. 

I think the cause of the greater fatality of compound dislocations over 
compound fractures is to be found in the simple fact that dislocations are 
generally reduced, and by splints or other apparatus successfully main- 
tained in place, while compound fractures, as my statistical report of 

1 Upon this point, see the very able article, entitled " Amputations and Compound 
Fractures," by John 0. Stone, in the New Journal of Medicine, vol. iii. of 21 series, 
p. 316, Nov. 1849. 



COMPOUND DISLOCATIONS OF THE LONG BONES. 885 

cases has proven, are not generally reduced completely, nor can they by 
any means yet devised, except in a few cases, be maintained in place if 
reduced. Broken limbs, whether simple or compound in their character, 
will in a great majority of cases shorten upon themselves in spite of the 
most assiduous and skilful attempts to prevent it. 1 

In adults most bones break obliquely, and cannot be made to support 
each other, and even in transverse fractures the broken ends are gener- 
ally small compared with the articular ends of the same bones, and afford 
a very uncertain and inadequate support for themselves ; not to speak of 
the difficulty of once bringing their ends into exact apposition where the 
muscles are powerful, or where they lie imbedded in a large mass of 
flesh so that they cannot be felt. While, on the other hand, dislocated 
bones, whether simple or compound, are capable, when restored to place, 
of supporting themselves ; or with only slight assistance, their reduction 
may be maintained ; it is also ordinarily a work of no great difficulty to 
reduce them. 

Herein, then, consists the most important difference between these two 
classes of accidents, which are in other respects so similar. In the one, 
the very nature of the injury prevents the complete reduction, and the 
consequent violent strain of the muscles, tendons, and other soft tissues ; 
while in the other, the nature of the accident leaves it in the power of the 
surgeon to reduce the bones, and modern surgery has in a great measure 
sanctioned the practice of maintaining them in place, in defiance of the 
efforts of the muscles, and sometimes, no doubt, at the imminent hazard 
of the life of the patient. 

Is it not fair to presume that tissues which have been stretched and 
lacerated, require rest in order that they may recover from the effects of 
their injuries ? And if the soft parts are really more injured in disloca- 
tions than in fractures, does not the indication for rest become for this 
very reason more imperative ? 

General Inferences. — We have come, then, to regard the shortening 
of limbs after fractures, within certain limits and in certain cases, as a 
conservative circumstance rather than as a circumstance which the sur- 
geon should in all cases seek to prevent. 

There is abundant evidence that the ancients had some knowledge of 
the value of rest to the muscles, tendons, etc., in the prevention of inflam- 
mation after compound dislocations, since they constantly urge the greater 
danger of reducing these dislocations, than of leaving them unreduced ; 
and they do not hesitate to recommend, that in case violent inflammation 
supervenes upon the reduction, the bone shall immediately be again dis- 
located. Galen speaks very explicitly on this subject, and says that 
" the danger in reduction consists partly in the additional violence in- 
flicted on the muscles, and partly in their being then put into a stretched 
state, whereby spasms or convulsions are brought on, and gangrene as 
the result of the intense inflammation which ensues ;" and Paulus iEgi- 
neta remarks : " For these, if reduced, occasion the most imminent dan- 
ger, and sometimes death ; the surrounding nerves and muscles being 
inflamed by the extension," etc. 

1 "Report on Deformities after Fractures." Trans. Am. Med. Assoc, vols. viii. , 
ix., and x. 



866 COMPOUND DISLOCATIONS OF THE LONG BONES. 

I have already quoted from Sir Astley Cooper the causes or reasons 
which he has assigned for the fatality of compound dislocations ; and 
the same reasons have generally been assigned by those who have 
written since his day ; but he has elsewhere, when speaking of exsec- 
tion, given place to the very idea for which we claim so much promi- 
nence, the danger arising from a stretching of the muscles. Mr. Listen, 
also, and Mr. Miller, when speaking especially of dislocations of the 
tibia at the ankle-joint, refer to the same source of danger. 

Treatment. — Let us see now the alternatives which surgery presents 
for the treatment of these intractable accidents. 

1. Reduction of the bone. 

2. Non-reduction. 
8. Amputation. 

4. Tenotomy. 

5. Resection and reduction. 

The questions for us to consider are, first, by which of these several 
methods is the life of the patient rendered most secure ? and, second, 
where, of two or more methods, all are equally safe, by which will he 
suffer the least maiming or mutilation ? 

By Reduction. — We have seen already how the old surgeons regarded 
the practice of reducing compound dislocations of the larger joints. It 
is not difficult, however, to find in the records of surgery numerous ex- 
amples of successful terminations under this practice. 

Dr. White, of Hudson, N. Y., has reported a case of this kind in 
which the dislocation was at the ankle-joint. 1 Pott says he has seen 
this practice occasionally succeed, 2 and Mr. Scott communicated to the 
Lancet, in March, 1837, a case of compound dislocation of the humerus 
successfully treated by reduction. Sir Astley Cooper also records 
several cases of compound dislocations at the lower end of the tibia and 
fibula, successfully treated by reduction. 

A careful examination, however, of those cases reported by Sir 
Astley as having been reduced without resection, and which resulted 
in cures, does not, in my opinion, leave much substantial evidence in 
favor of the practice ; or perhaps Ave ought rather to say that it leaves 
only a qualified evidence of its propriety in certain cases. He has 
mentioned about sixteen of these examples, comprising dislocations of 
the lower end of the tibia, or of the tibia and fibula, outwards, also 
inwards and forwards, all of which, save one quoted from Mr. Liston, 
have been reported to him by other surgeons, and not one of which 
had he ever seen himself. Many of the cases are reported very loosely, 
evidently in reply to circular letters, and from memory, without re- 
corded notes, and by unknown, and in some sense irresponsible, sur- 
geons. It is not always said whether the wounds in the soft parts 
were made by the protrusion of the bones, or by some external violence; 
yet this is certainly a very material point in determining whether re- 
duction is to be followed by inflammation or not. The results, some- 
times only attained after exposure to great hazards, are, after all, often 
sufficiently unfavorable. 

1 White, Amer. Journ. Med. Sci., Nov. 1828, p. 109. 

2 Pott, Chirurg. Works, vol. ii. p. 243. 



COMPOUND DISLOCATIONS OF THE LONG BONES. 867 

It will be noticed, also, that, in Cases 152 and 153, the astragalus 
was comminuted and removed, either at first or at a later day ; and in 
Cases 154, 155, 156, and 160, the tibia, and also probably the fibula, 
were broken, and it does not appear but that in consequence of this 
complication the limb became shortened, and the muscles were thus put 
at rest, very much as if the bones had been resected ; and in one of the 
cases enumerated under 161, the lower end of the tibia spontaneously 
exfoliated. That a comminution or that any fracture of the astragalus, 
or of the tibia and fibula, should be regarded in these cases as rendering 
the accident less grave, can only be comprehended by a full appreciation 
of the value of relaxation of the muscles. 

The few cases which remain after this exclusion do indeed illustrate 
how nature and skill may triumph over great difficulties, but nothing 
more. 

It is possible, also, that some of these examples of recovery after 
reduction may admit of an explanation entirely consistent with our 
own views of the true source of the danger in these accidents, if indeed 
they do not tend actually to confirm our doctrines. I have myself seen 
several examples of complete recovery after reduction of compound dis- 
locations at the ankle-joint, although resection was not practised ; in 
one of which, all the tissues, or nearly all which suffered any injury, 
were completely torn asunder, and therefore wholly removed from the 
danger of which we have spoken. The example referred to is the 
following: On the 30th of October, 1858, John Bourquard, set. 30, was 
caught in the tow-line of a canal-boat, causing a compound dislocation 
of the right ankle-joint. I found the foot, immediately after the acci- 
dent, thrown completely back against the lower part of the leg, the 
integuments in front of the joint, as well as all of the tendons and 
ligaments on this side, being completely torn asunder, while the tendo 
Achillis, and the tendons behind both of the malleoli, with the corre- 
sponding integuments, were uninjured. This immunity of the tissues 
behind the malleoli was due to the direction in which the foot was 
drawn, namely, directly backwards. Everything which had suffered 
a strain being thoroughly severed, I did not hesitate to attempt to save 
the limb without resection. The reduction was accomplished very 
easily. The leg and foot were placed in a box filled with bran, and 
cool water dressings were applied to the portion which was exposed. 
On the 22d of November the limb was removed from the bran to a 
pillow, the union being sufficient not to demand so much lateral sup- 
port. About the first of March he left the hospital, the wound having 
closed, but the ankle remaining swollen and stiff. 

I have also seen two cases in which the foot has been nearly severed 
from the leg through the ankle-joint, by means of a " reaper." In each 
case the patient was standing with his back to the machine, and one of 
the blades cut horizontally from side to side, severing everything except 
about three inches of integuments in front, and the extensor tendons of 
the toes. In the first instance, having seen the patient, a gentleman 
nearly sixty years of age, within three or four hours of the time of the 
receipt of the injury, I found him exceedingly exhausted by the hemor- 
rhage. Both malleoli were cut off smoothly, the knife having severed 



COMPOUND DISLOCATIONS OF THE LONG BONES. 

the limb so exactly through the joint, as to have touched the cartilage at 
but one or two points. Having secured the bloodvessels, I replaced the 
foot, and after a few days of attendance I left him in the charge of an 
excellent young surgeon, Dr. Eobertson, of Lancaster, N. Y., to whose 
diligence and skill the patient is no doubt mainly indebted for his recov- 
ery. After the lapse of nearly one year he was able, by the assistance 
of a shoe furnished with lateral supports, to walk very well. In the 
second case, which was only brought to my notice some months after 
the accident occurred, in consequence of a troublesome fistula near the 
ankle-joint, the recovery had been complete except that a small fragment 
of one of the malleoli was necrosed and required removal. 

Dr. Eli Hurd, of Niagara Co., N. Y., was equally fortunate in a case 
of compound dislocation of the shoulder-joint. This was in the person 
of G. T., set. 30, who was caught in the gearing of a threshing-machine 
on the 18th of February, 1852, which, having drawn him in with great 
force, dislocated the head of the left humerus downwards through the 
integuments into the axilla. Reduction was accomplished according to 
the method recommended by Nathan Smith, by pulling from each wrist 
at right angles with the body, while the operator himself seized the 
naked head of the humerus with his left hand, his right resting upon 
the top of the shoulder, and pushed it into place. The time occupied in 
the reduction was about thirty seconds. The forearm was then sus- 
pended in a sling, and the venous hemorrhage, occasioned by a rupture 
of the subclavian vein, was arrested by compression. The tegumentary 
wound, between three and four inches in length, was subsequently closed 
by sutures, and cool water dressings were applied. On the fourth day 
the wound had united by first intention, and the man was walking about 
his room. In less than a month he was dismissed cured, and in the fol- 
lowing harvest he was able to cut his own hay and grain, and to use his 
arm as before the accident. 1 

Miller and Hoffman reduced successfully a compound dislocation of 
the knee, 2 and Galli has communicated a similar case to Malgaigne. 3 

Whether either of the last three mentioned examples admit of the 
same explanation as the preceding three, I am unable to say, but whether 
they do or do not, they are too exceptional in their character to preju- 
dice the argument materially which we shall hereafter make in favor of 
resection. 

It is not pretended that the few cases which I have mentioned in the 
preceding pages are all of the compound dislocations successfully treated 
by reduction which have been recorded ; nor are they all which have 
come under my own observation; nevertheless, I repeat, success by this 
method has up to this moment, whatever plan of after-treatment has been 
adopted, been found to be the exception and not the rule. 

Non-reduction. — While it is true that not many cases of compound dis- 
locations, especially of the larger joints, can be found recorded as having 
terminated favorably after reduction, yet it will be very difficult to find 
an equal number of cases of compound dislocations, unreduced, which 

1 Hurd, Buffalo Med. Journ., vol. ix. p. 119. 

2 Miller and Hoffman, London Med. Repos., vol. xxiv. p. 346. 

3 Galli, Malgaigne, op. cit., torn. ii. p. 958. 



COMPOUND DISLOCATIONS OF THE LONG BONES. 869 

have terminated favorably. The fact is, no doubt, that at the present 
day very few surgeons would feel themselves justified in leaving a bone 
out of place unless they proceeded to amputate. In the Transactions of 
the Neiu York State Medical Society for 1855, I have reported (Case 
16 of Tibia and Fibula, p. 87) a compound dislocation at the ankle-joint, 
which, being unreduced, terminated fatally on the twenty-eighth day. 
This is the only example of a compound dislocation of a long bone, left 
unreduced, which has fallen under my observation; excepting, of course, 
those cases in which amputation was immediately practised. 

The united testimony, however, of the old surgeons, who generally 
neither amputated nor adopted the method of resection, but who recom- 
mended and practised non-reduction, is, that it is much more safe to 
leave these bones unreduced, than to reduce them without resection ; 
and I see no reason to doubt the correctness of their opinions in this 
matter. But whether it would be more safe to leave such limbs unre- 
duced, or having practised resection to restore them, is another question, 
in which the advantage and comparative safety of the latter practice are 
too obvious to require explanation or defence. 

Amputation. — Says Pott : " When this accident (dislocation of the 
ankle) is accompanied, as it sometimes is, with a wound of the integu- 
ments of the inner ankle, and that made by the protrusion of the bone, 
it not unfrequently ends in a fatal gangrene, unless prevented by timely 
amputation, though I have several times seen it do very well without." 
And Sir Astley Cooper, speaking of compound dislocations of the ankle- 
joint, remarks : "Thirty years ago it was the practice to amputate limbs 
for this accident, and the operation was then thought absolutely neces- 
sary for the preservation of life, by some of our best surgeons." Nor 
is it difficult to see by what reasoning surgeons of " thirty years ago" 
had fallen back upon this desperate remedy. Both reduction and non- 
reduction having proven eminently hazardous, in the absence of perhaps 
both knowledge and experience in resection, they finally adopted the 
alternative of amputation, as that which after all must give to the patient 
the best chance for life ; and were no other alternatives to be presented, 
this would be our choice in a large proportion of cases. 

It must not be understood, however, that amputation is an expedient 
wholly free from danger ; or, indeed, that the chances of the patient 
are in the average very greatly increased by this practice. Of thirteen 
amputations made for compound dislocations at the ankle-joint, in the 
Royal Infirmary at Edinburgh, only two resulted in the recovery of the 
patients. 1 Alluding to which, Mr. Fergusson remarks : "An amount of 
mortality which may well incline the surgeon to act upon the doctrine 
inculcated by Sir Astley Cooper" (to attempt to save the limb by re- 
duction). But Mr. Fergusson has added a sentiment which accords very 
closely with my own experience and opinions. " I fear, however, that 
in the attempts which have been made to save the foot (by reduction), 
the results in all the cases have not met with the same publicity — that 
the instances where amputation has been afterwards necessary, or where 
death has been the consequence, have not always been recorded ; and, 

1 Edinb. Med. Monthly, Aug. 1844. 



870 COMPOUND DISLOCATIONS OF THE LONG BONES. 

from what I have myself seen, I would caution the inexperienced prac- 
titioner from being over-sanguine in anticipating a happy result in every 
example." 

By Tenotomy. — As a means of overcoming the resistance of the mus- 
cles, and for the purpose especially of facilitating the reduction, tenotomy 
has been proposed. First by Dieffenbach in cases of ancient unreduced 
.luxations ; but Wm. Hey, Jr., was the first to make a practical applica- 
tion of this suggestion in a case of compound dislocation. After cutting 
the tendo Achillis, the ankle being dislocated, the reduction was easily 
effected, but a strong tendency to displacement backwards remained, 
and he was obliged afterwards to cut the tendons of the tibialis posticus 
and flexor lono-us digitorum. 1 

O CD 

This method, based in some degree upon a very correct notion of the 
principal sources of difficulty, I regard as totally impracticable, at least 
to any useful or adequate extent. In order to be efficient, all the ten- 
dons passing the articulations must be cut, or nearly all of them ; and I 
doubt whether the judgment of any discreet surgeon will ever sanction 
such an extreme, I might almost say such an absurd, measure. Nor do 
I think that in the point of view in which we are now considering this 
subject, having reference only to the question of danger, if the cutting 
of the tendons was sufficiently extensive to have any real effect in facil- 
itating the reduction, the practice would be found to have any advantage 
over other methods known to be eminently dangerous. 

By Resection. — Finally, resection presents itself for our consideration 
as the only remaining surgical expedient. 

We have seen that most of the early writers understood the effects of 
a constant strain upon the muscles in increasing the danger of spasms, 
inflammation, and death ; but in general they have suggested no remedy 
but non-reduction or amputation. Hippocrates, however, uses the fol- 
lowing language, after speaking of resection of protruding bones in acci- 
dental amputations or in fractures of the fingers : " Complete resection 
of bones at the joints, whether the foot, the hand, the leg, the ankle, the 
forearm, the wrist, for the most part, are not attended with danger, 
unless one be cut off at once by deliquium animi, or if continued fever 
supervene on the fourth clay." To which passage the translator adds 
the following note : " This paragraph on resection of the bones in com- 
pound dislocations and fractures contains almost all the information on 
the subject which is to be found in the works of ancient medicine." 
Oelsus notices the practice of resection in compound dislocations very 
briefly, as follows : " Si nudum os eminet, impedimentum semper futurum 
est ; ideo quod excedit, abscindendum est." 

Mr. Hey, of Leeds, was the first of modern surgeons who called espe- 
cial attention to the value of resection in compound dislocations. 

Subsequently, Mr. Parks, of Liverpool, in an " Account of a New 
Method of treating Diseases of the Joints of the Knee and Elbow," 
advocates the practice of resection in certain cases of diseases of these 
joints, but especially in u affections of the joints produced by external 
violence." 

1 Hey, Trans, of Provinc. Med. and Surg. Assoc, vol. xii. p. 171, 1844. 



COMPOUND DISLOCATIONS OF THE LONG BONES. 871 

M. Leveille, in France also, following, as he affirms, the guidance of 
Hippocrates, has advocated a similar practice. 

Velpeau, Syme, Fergusson, Erichsen, Miller, Liston, Chelius, Lizars, 
Gibson, Norris, under certain circumstances, and especially where the 
bones cannot otherwise be reduced, and where the dislocations occur in 
certain joints, and especially the elbow and ankle-joints, recommend 
resection. To which names we may add that of Sir Astley Cooper, 
who has considered the subject, as applied to the ankle-joint, quite at 
length, and who says : " I have known no case of death when the ex- 
tremities of the bone" (tibia, at the ankle) " have been sawed off', 
although I shall have occasion to mention some cases which terminated 
fatally when this was not done." 

Why resection should diminish the danger to life, by placing at rest 
the injured muscles, has been already sufficiently considered: but it 
seems not improbable that, if synovial membranes are actually more 
susceptible of violent and dangerous inflammations than the other tissues 
about the joints, then would this source of danger be removed just in 
proportion as the synovial membranes themselves are removed. Such, 
indeed, was the argument used by Sir Astley ; and Mr. South, in a note to 
Chelius, when referring to this fact, has made the following statement : — 

u In compound dislocations of the ankle-joint, with protrusion of the 
shin-bone through the wound, most English surgeons saw off the joint 
end, not merely to render reduction more easy, but also, according to 
Sir Astley Cooper's opinions, to lessen the suppurative process, by 
diminishing the synovial surface. This mode of practice is certainly 
not commonly followed in reference to other joints, and the younger 
Cline was always opposed to its being resorted to in dislocated ankle." 

The following cases having occurred under my own eye, will serve 
to illustrate the value of the principle which I have been endeavoring 
to establish : — 

Samuel xldamson, of Buffalo, aet. 24, was caught by the cable of a 
vessel, June IT, 1855, dislocating the left tibia at its lower end in- 
wards, and breaking the fibula two inches above the ankle. I was 
immediately called, and found the tibia protruding through the skin 
about three inches. The periosteum was torn up, and the cartilaginous 
surface of the end of the bone was rous-hened. His thigh was also 
severely bruised and lacerated, but the bone was not broken. 

Dr. Boardman assisting me, we attempted to reduce the bones, but 
with our hands we found it impossible to do 'so. I proceeded imme- 
diately to remove about one inch and a half of the lower end of the 
tibia with the saw. The remaining portion was then brought easily 
into place, and the wound dressed with sutures, adhesive strips, band- 
ages, and light splints. On the same day he became an inmate of the 
marine wards at the Hospital of the Sisters of Charity, and was placed 
under the care of Dr. Wilcox, through whose politeness I was permitted 
to see him frequently. 

The wound in the leg healed kindly, with only a slight amount of 
inflammation and suppuration. Violent inflammation, however, occurred 
in the thigh, followed by extensive suppuration and sloughing. This, in 
fact, proved to be by far the most serious injury, and that which most 
endangered his life and delayed his recovery. 



872 COMPOUND DISLOCATIONS OF THE LONG BONES. 

After about two months, the ankle was in such a condition as to re- 
quire little or no further attention. The fragments of the fibula had 
shortened upon each other and were united, so that the tibia rested upon 
the astragalus. It was nearly two months, however, before he began to 
walk, owing to the condition of his thigh. 

August 24, 1856, fourteen months after the accident, Adamson called 
at my office. He was then employed again as a sailor on board the 
schooner Sebastopol, and performed all the duties of an ordinary deck- 
hand. His leg is shortened one inch and a quarter; from which, it 
seems, that there has been some deposit upon the end of the bone, which 
has compensated for one-quarter of an inch of that which I removed. 
The ankle is perfect in its form, being neither turned to the right nor to 
the left, and he treads square and firm upon the sole of his foot. There 
is considerable freedom of motion, especially in flexion and extension. 
Occasionally it becomes a little swollen and painful. 

January 1, 1875, Rosanna Wilbur, set. 45, was admitted to ward 13, 
Bellevue, having just been injured by a street car. She was in good 
health, but very fat, weighing 185 lbs. She was found to have a com- 
pound dislocation at the right ankle-joint — the tibia being thrust com- 
pletely through the flesh — and also a fracture of the fibula. Dr. Lewis, 
the house surgeon, reduced the dislocation at once, and easily, and then 
sent for me. I advised an attempt to save the limb without resection, 
and by supporting the limb with the plaster-of-Paris dressing. This 
dressing was applied fourteen hours after the accident by Dr. Lewis, a 
window being made opposite the ankle. January 3, the window was 
enlarged. January 5, gangrene and phlebitis had occurred; fenestra 
again enlarged. January 7, entire splint laid open, and hot-water dress- 
ings applied. January 12, suspended limb. January 21, the condition 
of the limb very critical ; and, in a consultation composed of the visiting 
surgeons, we were equally divided between amputation and resection. 
It was permitted, therefore, that I should choose my own course. I 
immediately resected two inches of the lower end of the tibia, and placed 
the limb again in a sling supported with compresses as means of lateral 
support, and warm-water dressings were continued. The subsequent 
progress of the case was very slow, and there were several smart attacks 
of erysipelas, so that her life was at times in danger; but finally all 
unfavorable symptoms disappeared, and on the 1st of May, the ankle 
was in perfect shape, admitting of some flexion and extension, and the 
wounds were almost completely closed. It is now apparent, that a re- 
section on the first day would have been the most judicious practice, 
but that even at a later day it saved her life. 

In a case of compound dislocation of the upper end of the humerus, 
occurring also under my own observation, and recorded in the Transac- 
actions of the New York State Medical Society for 1855 (p. 27, Case 14), 
in which reduction was followed by death, I have now much reason to 
believe that if I had practised resection before the reduction, my pa- 
tient's chances for recovery would have been greatly increased ; perhaps 
also the case of compound dislocation at the wrist-joint recorded in the 
same volume (p. 68), in which, having reduced the bones, I was subse- 
quently compelled to amputate, may equally illustrate the hazard to 



COMPOUND DISLOCATIONS OF THE LONG BONES. 873 

which the practice of reduction without resection must often expose the 
patient. 

The same remarks I will venture to apply to the case of compound 
dislocation of the hip, of which I have already spoken as having occurred 
in the practice of Dr. Walker, of Charlestown, Mass. Had the head of 
the femur been resected before its reduction, I cannot doubt but that the 
unfortunate man's chance for recovery would have been very greatly 
improved. 

Thus, if we consider the question of the life of the patient only, the 
argument and the testimony seem to favor resection, in a great majority 
of cases of compound dislocations occurring in large joints, and in a con- 
siderable number of cases of similar accidents in the smaller joints. It 
is certainly more safe than non-reduction or reduction without resection, 
and it is probably quite as safe as amputation or tenotomy. 

But there is another question, which is, in our estimation, secondary 
to the one now considered, but which is often in the estimation of the 
patient himself of the first importance, namely, by which method will he 
suffer the least maiming or mutilation? 

This question I do not find it difficult to answer. Certainly it is not 
by non-reduction or by amputation; and, putting tenotomy aside, it is 
now a question only between reduction without resection, and reduction 
with resection. These two methods, one of which experience has shown 
to be fraught with danger, and the other of which experience has shown 
to be relatively safe, are now to be compared in a point of view in which 
their antagonisms are perhaps less conspicuous, yet sufficiently marked. 

First. In either case the inflammation consequent upon the injury 
may be violent, and the recovery slow and tedious. The same argu- 
ments, however, which we have applied to the question of the compara- 
tive danger of the two modes, must apply with nearly equal force to this 
question of maiming; since the amount of maiming must often be gov- 
erned by the intensity and duration of the inflammation, and upon this 
point the testimony has been shown to be in favor of resection. 

It will be observed that not only is the danger of maiming rendered 
more considerable by reduction without resection, because the inflam- 
mation is so much more likely to extend to the tendons and muscles, 
causing them to adhere to each other, and to become subsequently atro- 
phied, a condition from which they often never completely recover; but 
also because the ligaments and capsules of the joints, with the synovial 
surfaces, are in consequence encroached upon, and the freedom of motion 
is ever afterwards greatly restricted, if not completely lost. This marked 
impairment of the functions of the joint does not always happen, but it 
cannot be denied that it does generally. Indeed, it is by no means un- 
common for these accidents to be followed, after ulcerations of the car- 
tilage, by copious bony deposits in and around the joints. 

How is it, on the other hand, with these joints after resection ? I 
have thus far heard of no cases in which complete anchylosis resulted ; 
but in all considerable freedom of motion has returned, and in some the 
restoration in this respect has been nearly or quite as complete as before 
the accident. 

Says Dr. Kerr, of Northampton : " Several cases of compound dis- 

56 



874 COMPOUND DISLOCATIONS OF THE LONG BONES. 

location of the ankle have fallen under my care, and it has been uni- 
formly my practice to take off the lower extremity of the tibia, and to 
lay the limb in a state of semiflexion upon splints ; by this means a 
great degree of painful extension and the consequent high degree of 
inflammation are avoided. The splints I used are excavated wood, 
and much wider than those in common use, with thick movable pads 
stuffed with wool. I keep the parts constantly wetted with a solution 
of liquor ammonige acetatis, without removing the bandage. In my 
very early life, upwards of sixty years ago, I saw many attempts to 
reduce compound dislocations without removing any part of the tibia ; 
but, to the best of my recollection, they all ended unfavorably, or, at 
least, in amputation. By the method which I have pursued, as above 
mentioned, I have generally succeeded in saving the foot, and in pre- 
serving a tolerable articulation." 

Sir Astley Cooper has made a valuable experiment to determine the 
condition of the new joint under these circumstances ; and the vast 
number of examples in which resection has now been practised in cases 
of caries of the articulating surfaces, and their results, add still more 
substantial proofs as to the usefulness of the joints after such opera- 
tions. 

u I made an incision upon the lower extremity of the tibia, at the 
inner ankle of a dog, and, cutting the inner portion of the ligament of 
the ankle-joint, I produced a compound dislocation of the bone in- 
wards. 1 then sawed off the whole cartilaginous extremity of the 
tibia, returned the bone upon the astragalus, closed the integuments by 
suture, and bandaged the limb to preserve the bone in this situation. 
Considerable inflammation and suppuration followed ; and in a week 
the bandage was removed. When the wound had been for several 
w T eeks perfectly healed, I dissected the limb. The ligament of the 
joint was still defective at the part at which it had been cut. From 
the sawn surface of the tibia there grew a ligamento-cartilaginous sub- 
stance, which proceeded to the surface of the cartilage of the astragalus 
to which it adhered. The cartilage of the astragalus appeared to be 
absorbed only in one small part ; there was no cavity between the end 
of the tibia and the cartilaginous surface of the astragalus. A free 
motion existed between the tibia and astragalus, which was permitted 
by the length and flexibility of the ligamentous substance above de- 
scribed, so as to give the advantage of a joint where no synovial articu- 
lation or cavity was to be found. This experiment not only shows 
the manner in which the parts are restored, but also the advantage of 
passive motion ; for, if the part be frequently moved, the intervening 
substance becomes entirely ligamentous ; but, if it be left perfectly at 
rest for a length of time, ossific action proceeds from the extremity of 
the tibia into the ligamentous substance, and thus produces an ossific 
anchylosis." 

Second. Is it not probable, moreover, since the limb can be retained 
in place so much more easily after resection, that it will actually, in a 
majority of cases, be found to have been retained in place more per- 
fectly ? Even after simple dislocations, especially in those occurring 
at the ankle-joint, great deformity and much maiming are the not un- 



COMPOUND DISLOCATIONS OF THE LONG BONES. 8T5 

frequent results, and that, too, when all diligence and care have been 
employed. It has been impossible always to maintain a perfect apposi- 
tion in the articulating surfaces. How much greater must be this diffi- 
culty in cases of compound dislocations. 

Third. The only argument which remains in favor of reduction with- 
out resection is the necessary shortening of the limb after resection. 
But this need seldom perhaps to exceed three-quarters of an inch, and 
often not more than half an inch ; an amount of shortening which, as I 
have had occasion to prove when treating of fractures, does not neces- 
sarily produce a halt, and which indeed is often not known to exist by 
the patient himself. The experience of Heine, Langenbeck, Volkman, 
Hueter, and other German surgeons, has shown that in a considerable 
number of cases, when these resections have been made by the subperi- 
osteal methods, no shortening whatever has resulted. 1 

Finally. It must not be inferred that the author intends to recom- 
mend resection as a universal practice in cases of compound dislocations 
of the long bones. He has only sought to determine in a general 
manner its relative value as compared with other modes of procedure ; 
and especially has it been his intention to bring more prominently into 
view the importance of rest and relaxation to the muscles, as an ele- 
ment in the treatment most essential to success. To declare its special 
application to cases would demand a treatise more elaborate than it was 
proposed to write. If, however, one were to speak of the individual 
bones only, there seems sufficient authority in the facts and arguments 
already presented, to conclude that resection is applicable to certain 
compound dislocations of the clavicle, humerus, radius, and ulna, fingers, 
femur, tibia, fibula, and toes ; in short, to a certain proportion of all 
these accidents occurring in the long bones of the extremities. 

If an attempt is made to save the limb without resection, it is scarcely 
necessary to say that the success will depend, in a great measure, upon 
the care, attention, and skill bestowed upon the treatment. The limb 
must be maintained in a position of rest, combined with moderate eleva- 
tion ; and warm water or other suitable dressings assiduously applied. 

1 On Subperiosteal Resection of the Tibio-tarsal Articulation. By Achilles Rose, 
M.D., New York. The Medical Record, July 3, 1875. 



876 CONGENITAL DISLOCATIONS. 



CHAPTEE XXYI. 

CONGENITAL DISLOCATIONS. 

§ 1. General Observations and History. 

We have omitted, until this moment, to speak of Congenital Disloca- 
tions, because, whatever theory of causation we adopt, dissections have 
shown that they are generally, in some sense, pathologic, or are accom- 
panied with such essential modifications of the anatomical structures as 
to separate them entirely from ordinary traumatic luxations, which alone 
constitute the proper subjects of consideration in the present treatise. 
In relation to congenital dislocations, we shall find it necessary to estab- 
lish systems of etiology, symptomatology, prognosis, and treatment, 
having very few points in common with traumatic dislocations. Excep- 
tions to this rule will occur, in examples of intra-uterine traumatic luxa- 
tions, existing at birth without either original or accidental malformations 
of the articulations, or of the adjacent muscular, tendinous, or ligamen- 
tous structures ; yet only in sufficient numbers to warrant the intrusion 
of the subject in this place. 

It is probable that congenital displacements may occur in all the artic- 
ulations of the skeleton ; and in most of them their existence has been al- 
ready established by dissections. Until within a few years, however, 
the attention of surgeons has been almost entirely directed to congenital 
dislocations of the shoulder and hip. 

Hippocrates, in his treatise u De Articulis," speaks expressly of dislo- 
cations of the hip occurring in the mother's womb, comprising them under 
the same order with the different varieties of club-foot. 

Avicenna and Ambrose Pare' have each mentioned congenital disloca- 
tions of the hip ; but the first to record an example with any degree of accu- 
racy was Kerkrmg ; in which case, death having occurred during infancy, 
he was able to verify his opinion by an autopsy. Chaussier has reported, 
in the Bulletin de la Faculteet de la Sociele de Medecine, An. 1811 and 
1812, the case of an infant, upon which he discovered, at birth, two dis- 
locations, one at the scapulo-humeral articulation, and the other at the 
coxo-femoral. In 1788, Palletta, of Milan, published, under the title of 
Adversaria Chirurgica, a collection of observations, in which, among 
other things, he has described certain congenital malformations of the hip- 
joint; and in 1820 he published another work, entitled Exercitationes 
l J atholoc/icce, where he enters into a more complete exposition of the na- 
ture and causes of these deformities. 

In 1826, Dupuytren read, before the Academy of Sciences, a memoir 
upon the lameness produced by the original displacement of the femur ; 
and in the Legons Orales, published in the collections of the Sydenham 



ETIOLOGY. 8<7 

Society, may be found a full record of the views and observations of this 
distinguished surgeon. 

The writings of Dupuytren seem, more than anything previously writ- 
ten, to have directed the attention of surgeons and pathologists to this 
interesting subject, and to have given a new impulse to investigation. 

From this time various treatises have been written by eminent surgeons, 
many of which are characterized by profound thought, careful investiga- 
tion, and practical experiment. 

Among those who have furnished us lately with elaborate treatises, or 
with more precise practical information upon this subject, the following 
names deserve to be especially mentioned : Breschet, 1 Caillard-Billion- 
iere, 2 Lehoux, 3 Sandiforte, 4 Duval and Lafond, Humbert and Jacquier, 
Bouvier, 5 Se'dillot, 6 Gerdy, Poliniere, Wrolik, 7 Guerin, 8 Parise, 9 Pravaz, 10 
Carnochan, 11 and Robert Smith. 12 

§ 2. Etiology. 

Hippocrates says that the bones of the extremities may be disarticu- 
lated during intra-uterine life by falls or blows, or by injuries of any 
kind, inflicted directly upon the abdomen of the mother. 

Ambrose Pare*, while admitting the efficiency of the several causes 
named by Hippocrates, believed also that the contractions of the womb, 
and violence employed by the accoucheur, were occasionally adequate to 
the production of the same result. He taught, moreover, that the posi- 
tion of the foetus itself might favor the displacement; and that, in some 
instances, an articular abscess, insufficient depth of the socket, with a 
laxity of the ligaments, were competent to determine the expulsion of the 
head of the femur from its natural position. 

Sddillot regards a softening and relaxation of the ligaments as the 
most frequent cause. 

Parise and Malgaigne are disposed to attribute a majority of these 
cases to hydrarthrosis, or water in the joints. Says Malgaigne : " For 
myself, after having long meditated upon this subject, I have come to 
think that inflammation of the joints enjoys a grand role, both in coxo- 
femoral dislocations and in many others, and even also in various con- 

1 Breschet, Repertoire d'Anatornie et de Physiologie. 

2 Caillard-Billioniere, These Inaugurale, 1828. 

3 Lehoux, These Inaugurale, 1834. Paris. 

* Sandiforte, Thesis, sustained before the Faculty of Med. of Leyden. 

5 Duval and Lafond, Humbert and Jacquier, Bouvier. See Pravaz. 

6 Sedillot, Journ. de Connais. Med.-Chirurg., 1838. 

7 Gerdy, Poliniere, Wrolik. See Pravaz. 

8 Guerin, Recherches sur les Luxations Congenitales ; par Jules Guerin. Paris, 
1841. 

9 Parise, Archiv. Gen. de Med., 1842. 

10 Pravaz, Traite Theorique et Pratique des Luxations Congenitales du Femur, suivi 
d'un Appendice sur la Prophylaxie des Luxations Spontanees ; par Ch. G. Pravaz, 
Lyons, 1847. 

11 Carnochan, A Treatise on the Etiology, Pathology, and Treatment of Congeni- 
tal Dislocations of the Head of the Femur ; by John Murray Carnochan, New York, 
1850. 

12 R. Smith, A Treatise on Fractures in the Vicinity of Joints, and on Certain Acci- 
dental and Congenital Dislocations. Dublin, 1854. 



8<8 CONGENITAL DISLOCATIONS. 

genital malformations generally ascribed to arrest of development." This 
writer admits, however, that it will not do to generalize too much in this 
matter, and that the etiology of congenital luxations is probably as com- 
plex as that of luxations after birth. 

Chaussier seems to have regarded muscular contraction, or the occur- 
rence of an intra-uterine convulsion, as the cause of the example of con- 
genital dislocation of both humerus and femur seen and recorded by 
him. Since whom Guerin has greatly extended the application of this 
doctrine, having embraced in the same etiologic formula all or nearly 
all congenital dislocations. Gudrin ascribes to muscular contraction in 
one form or another, and to corresponding muscular paralysis, not only 
dislocations of the femur and other long bones, but also club-foot, torti- 
collis, and various other deviations of the spine. He affirms, moreover, 
that he has established incontestably the dependence of this abnormal 
state of the muscular system upon the absence or disappearance more or 
less complete of corresponding portions of the central nervous systems. 

Breschet and Delpech maintained similar views, especially in relation 
to the dependence of the several varieties of club-foot upon some morbid 
condition of the cerebro-spinal axis. While Carnochan remarks as fol- 
lows : "■ It appears most in accordance with science to refer the muscu- 
lar spasmodic retraction, upon which congenital dislocations of the head 
of the femur from the cotyloid cavity depend, to a perverted condition of 
the excito-motor apparatus of the medulla spinalis, and more especially 
of that portion of it which is in direct relation with the reflex-motor ner- 
vous fibres, distributed to the pelvi-femoral muscles surrounding, and in 
connection with, the ilio-femoral articulation." 

Palletta ascribes these deformities solely to an original defect of the 
germ ; and Dupuytren also declares that, in the case of a congenital dis- 
location of the hip, the causes are coeval with the earliest organization 
of the parts, and that the displacement is due rather to a defect in the 
depth or completeness of the acetabulum, than to accident or disease. 

Breschet and Delpech, both of whom, as we have already stated, refer 
them to some morbid condition of the cerebro-spinal axis, imagine that 
in consequence of this morbid condition of the nervous centres, there 
exists an arrest of development in the bones, muscles, ligaments, sockets, 
and, in short, through all the apparatus of the joint which is the seat of 
the deformity. 

If we proceed to analyze these various opinions, we shall find that 
they are so far susceptible of classification, as that they may be arranged 
under the three following divisions : — 

First, the physiological doctrines ; according to which congenital dis- 
locations are due to an original. defect in the germ, or to an arrest of 
development. 

Second, the pathologic doctrines ; which refer them to some supposed 
lesion of the nervous centres, to contraction or paralysis of the muscles, 
to a laxity of the ligaments, to hydrarthrosis, or to some other diseased 
condition of the articulating apparatus. 

Third, the mechanical doctrines ; which recognize no intra-uterine dis- 
locations except those which are strictly traumatic. The causes being 
understood to be the peculiar position of the foetus in utero, violent con- 



CONGENITAL DISLOCATION'S OF INFERIOR MAXILLA. 879 

tractions or the constant pressure of the walls of the uterus, falls and 
blows upon the abdomen, and unskilful manipulation of the child in 
delivery. 

After a full and careful consideration of this subject, we are prepared 
to admit the occasional agency of all the causes enumerated, and the 
probable concurrence of two or more in many instances ; nor do we see 
the propriety of rejecting, as Malgaigne has done, all that large class of 
malformations, which seem to depend upon an arrest of development, or 
those which appear to be due mainly or solely to intra-uterine paralysis, 
of both of which many examples have been reported. 

§ 3. Congenital Dislocations of the Inferior Maxilla. 

Malgaigne affirms that " we know of no congenital dislocation of the 
jaw," and that we are " not to take seriously the pretended luxation 
observed by Guerin upon a derencephalous infant." The example 
recorded by Robert Smith he rejects also, declaring that he does " not 
comprehend how one can see in it a luxation." 

For myself, I know of no reason why we should not take " seriously" 
the case mentioned by Guerin, since, so far as appears in his very brief 
report of the same, it might have been a true luxation. The specimen 
w~as before the Academy, and if Malgaigne, from a personal examination, 
has become satisfied that a dislocation did not exist, he ought to have so 
informed us. But since he does not speak of having made it the subject 
of special examination, we shall feel compelled to accept of it as reported 
by Guerin. 

As to the objection offered to Mr. Smith's case, namely, that " aside of 
the complete absence of its history, the subject did not present the char- 
acteristic signs of luxation, and the dissection discovered neither maxil- 
lary condyle nor glenoid cavity," we must reply, the dissection seems to 
us to have furnished such evidence that the deformity was congenital as 
to render its history unnecessary ; the signs were characteristic, not 
indeed of a traumatic luxation, but of a congenital dislocation, such as 
may be supposed to have been the result of an arrest of development, or 
of an original aberration of the germ. 

The following is a summary of the very complete account of this case 
given by Robert Smith. 

On the 5th of May, 1840, Edward Lacy, set. 38, an idiot from infancy, 
died at the Hardwick Hospital, in consequence of gangrene of the lungs. 
While making the autopsy, a singular deformity of the face was discov- 
ered. The right and left sides seemed as though they did not belong to 
the same individual, the left being in every respect more fully developed. 
Upon removing the integuments, the muscles of the right side were found 
to be much smaller than those of the left, and especially the masseter. 
These latter having been removed also, the condition of the right tem- 
poro-maxillary articulation was carefully studied. 

When the mouth was closed, the external lateral ligament, instead of 
being directed backwards, was seen descending obliquely forwards, to be 
attached to a very imperfectly developed condyle situated at least one- 
quarter of an inch in front of its natural position. There was neither an 



880 CONGENITAL DISLOCATIONS. 

interarticular cartilage nor cartilage of incrustation, the joint surfaces 
being invested by a thick periosteum alone ; nor was there any distinct 
capsular ligament. 

Nearly the whole of the right side of the inferior maxilla was smaller 
than the left. The condyle was short and curved, being directed nearly 
horizontally inwards, and resembling much more the coracoid process 
than the condyle of the inferior maxilla. The coronoid process was very 
small and thin, and the sigmoid notch could scarcely be said to exist. 

The articular eminence of the temporal bone was absent, there being 
in its place nearly a flat surface destitute of cartilage ; which surface 
presented upon its inner side a shallow and semicircular sulcus where 
the hooklike condyle of the lower jaw had played. 

The malar, superior maxillary, and sphenoid bones of the right side 
had also suffered corresponding changes of form and relative size. 

The motions permitted in the lower jaw were more extensive than 
those which it enjoys in its normal condition, that is, upon the right 
side the ramus could be moved very freely forwards and backwards, 
while upon the left, the condyle underwent a species of rotation upon its 
axis. During life the patient was observed to be constantly performing 
this motion, and the right side of the face was continually affected with 
spasmodic twitches. When the mouth was closed, the front teeth of the 
upper jaw projected beyond those of the lower, and when opened the 
deformity was in all respects greatly increased. 1 

Mr. Smith takes this occasion also to express his dissent from the 
views maintained by Ribes, namely, that the formation of the glenoid 
cavity is consequent upon the growth of the condyle, and that, were this 
process not formed, there would not exist either a glenoid cavity or an 
articular eminence. It is true that neither the glenoid cavity nor the 
articular eminence is found in the foetus. Until the seventh month of 
intra-uterine life there exists at this point of the temporal bone only a 
plane surface, and the glenoid cavity with its corresponding eminence is 
developed in proportion to the growth and development of the condyle. 
But Mr. Smith justly observes that although the development of the con- 
dyle does precede that of the glenoid cavity, " it by no means follows that 
the formation of the latter is due to the pressure of the former." The 
cavity, or rather the transverse eminence in front of the plane surface, 
does not exist in foetal life, because, owing to the peculiar form of the 
inferior maxilla at this period, its existence is not necessary. The ver- 
tical portion of the jaw (vertical only in the adult) is in the foetus nearly 
in the same line with the axis of the shaft, and consequently when the 
mouth is opened by the action of the muscles, the condyles are pressed 
upwards and backwards instead of upwards and forwards, as in the adult. 
A displacement forwards cannot therefore very well occur; and the pro- 
tection of the articular eminences is not required. As age advances the 
angles of the jaw increase, the portions upon which the condyles rest 
become more vertical, and finally a displacement forwards would occur 
whenever the mouth was well opened if the articular eminences were not 
present to afford a sufficient protection in front. 

1 Robert Smith, op. cit., p. 283. 



CONGENITAL DISLOCATIONS OF INFERIOR MAXILLA. 881 

In the case of Lacy the foe'al condition of the bones upon one side 
remained during life, there being neither cavity nor eminence, and the 
condyle itself being only imperfectly developed ; but the angle of the 
jaw had assumed the form which belongs to the adult, and the ascending 
ramus was vertical, consequently the condyle became somewhat dis- 
placed forwards. 

Chronic rheumatic arthritis is occasionally found in the temporo-max- 
illary articulation of old persons ; and it may be important to distinguish 
it from congenital luxation, with which, owing to the absorption of the 
articular eminence, and the consequent displacement of the condyle, it 
might possibly be confounded. 

Says Mr. Smith: " In a majority of instances, this remarkable disease 
attacks those of advanced age, and is symmetrical; but occasionally it 
occurs during the period of adult life. In the latter case it is generally 
more rapid in its progress, is accompanied by greater pain, and is more 
liable to implicate the neck of the condyle, and the ramus of the jaw." 

When the condyle is implicated it becomes enlarged, and can be felt 
beneath the zygoma, in front of the meatus externus. The lymphatic 
glands of this region are sometimes enlarged, and the progress of the 
malady is attended with a constant but not generally severe pain. 

The deformity of the face varies according as one or both articulations 
are affected. When the malady is confined to one joint, the chin is 
thrown slightly forwards, but chiefly to the opposite side, and when both 
are implicated, the chin is simply advanced so that the teeth project be- 
yond those of the upper jaw. 

As the disease progresses, the glenoid cavity enlarges by absorption, 
and at length a considerable portion or the whole of the articular emi- 
nence disappears and the jaw becomes gradually displaced through the 
action of the external pterygoids. The disease does not extend in the 
temporal bone beyond the articulating surface of the glenoid cavity. 
The condyle assumes a variety of forms, sometimes being greatly en- 
larged in all its diameters, while its upper surface may be flattened, or 
conical. The interarticular cartilage disappears ; but Mr. Smith has never 
yet found any foreign bodies in the joint, and in only one instance have 
the surfaces been polished or eburnated as we often see in examples of 
chronic rheumatic arthritis occurring in the hip, knee, and other joints. 

The following is an excellent summary of the diagnostic marks be- 
tween congenital, accidental, and rheumatic dislocations, given by this 
writer: — 

" 1. In the congenital luxation, the mouth can be freely opened and 
closed ; in chronic rheumatism these motions can be performed, but 
not without uneasiness to the patient, an uneasiness which sometimes 
amounts to severe pain ; in luxations from accident, the mouth cannot be 
closed. 

" 2. An involuntary flow of saliva accompanies the accidental luxa- 
tion alone, although in some cases of chronic rheumatism there is an 
increased secretion of that fluid. 

" 3. In congenital luxation, the teeth of the upper jaw project beyond 
those of the lower; the reverse is observed in accidental luxation and in 
chronic rheumatism. 



882 CONGENITAL DISLOCATIONS. 

" 4. In congenital luxation there is no fulness in the cheek, such as 
the coronoid process produces in cases of accidental luxation, and the 
condyle is not enlarged, as in some instances of chronic rheumatic 
arthritis." 1 



§ 4- Congenital Dislocations of the Spine. 

Says Guerin, of the subluxation oceipito-atloidean there are two 
varieties : " First. Backwards, consisting in an exaggerated flexion of 
the head upon the front of the neck and chest, with a commencement of 
sliding backwards of the occipital condyles upon the articular facets of 
the atlas. Here are two examples in foetal anencephalous monsters. 
Second. Forwards. Those who follow my consultations can recollect 
having seen last year an infant, about tw r o or three months old, who 
offered a remarkable example. The head was exactly applied against 
the posterior part of the neck, and upper part of the back. There was 
probably a sliding of the condyles forwards, with elongation of the 
anterior ligaments." 2 

The existence of the first of these varieties has since been denied by 
Guerin himself ; 3 and it will be noticed that he only speaks of the second 
as a probable subluxation forwards. Neither of them can therefore be 
regarded as established. 

Guerin further remarks that he has observed subluxations in the other 
regions of the spinal column many times ; and he showed to the Academy 
a foetus in which the spine presented, besides the occipitoatloidean dis- 
placement, a series of angular flexions in the antero-posterior direction, 
with sliding of the articular surfaces. 

In attempting to appreciate the value of Guefin's observations upon 
this point, it must be remembered that he regards all cases of congenital 
torticollis, and other deviations of the spine, as examples of subluxation ; 
and, in some sense, Ave think the theory of this distinguished surgeon 
may be regarded as correct. The amount of articular displacement 
between each of the adjacent vertebrae may be very inconsiderable in 
any such case, yet, however trivial, if it exceeds the limits of natural 
motion, it may properly enough be regarded as the commencement of a 
luxation. 

§ 5. Congenital Dislocations of the Pelvic Bones. 

Bassius speaks of a diastasis or separation of the sacro-iliac symphy- 
sis, observed by him in newly born children, and in infants ; but, accord- 
ing to Malgaigne, his account of these cases is not such as to warrant 
any conclusions as to the true nature of the displacements. 

Congenital exstrophy of the bladder is accompanied always with a 
deficiency of the central and upper portions of the pubic bones, the 
result manifestly of an arrest of development ; but these cases, of which 
I have seen several examples, are not properly examples of congenital dis- 
locations, but only of diastases, the separated portions remaining in their 

i R. Smith, op. cit., p. 292. 2 Guerin, op. cit., 1841, p. 29. 

3 Ibid., op. cit., p. 32. 



CONGENITAL DISLOCATIONS OF THE CLAVICLE. 883 

normal position with reference to each other, except that they are not 
prolonged sufficiently to meet in the median line. 

GueVin declares, however, that he has seen congenital displacement, 
or overriding of the iliac bone upon the sacrum, accompanied with coxo- 
femoral dislocation and curvature of the spine. The same writer men- 
tions an example, in a foetal monster, of diastasis of the pubic bones, and 
of the sacro-iliac symphysis, accompanied with a turning out of the pubes 
upon the external face of the ischium. 1 

§ 6. Congenital Dislocations of the Sternum. 

Seger alone has reported one example of luxation of the xiphoid car- 
tilage from the sternum. 

A woman in her fifth month of pregnancy fell and dislocated her 
shoulder. Just four months after this she was brought to bed with an 
infant, well formed, except that, soon after it was born, the ensiform car- 
tilage was observed to be remarkably movable, especially when the child 
hiccoughed, to which it was very subject. The cartilage was separated 
from the sternum by the breadth of the little finger. No treatment was 
employed ; the cartilage gradually became restored to its place, and in 
about one year it was firmly united to the sternum. 2 

§ 7. Congenital Dislocations of the Clavicle. 

Malgaigne says that a congenital dislocation at the sterno-clavicular 
articulation has never been observed ; but Guerin declares that he has 
established the existence of three varieties, namely : — 

1. A luxation of the sternal end of the clavicle inwards and forwards ; 
this extremity of the clavicle lying in front of the sternal fourchette. In 
illustration of which he presented to the Academy a plaster cast of a girl 
eight years old, in whom the displacement existed upon both sides. 

2. Inwards and upwards. Observed by him in a girl eight years old; 
but which displacement took place only when the arm was moved, and 
through the contraction of the sterno-cleido-mastoideus muscle. 

3. Backwards. Of which he presented two examples in the corre- 
sponding sides of a foetal monster. 

I believe I have already referred to Fergusson's case of dislocation of 
the sternal end of the clavicle forwards, w T hich occurred during birth. 
The end rested in front of the sternum, and could be pushed into its 
place with great ease ; but when left alone it immediately slipped out 
again. Nothing was done, a new joint formed, and the child afterwards 
possessed as much power in the one arm as in the other. 3 

Guerin says that he has seen a dislocation upwards and outwards at 
the acromial end of the clavicle in a foetus of three months. And I 
have mentioned, in the chapter on Traumatic Dislocations of the Bones, 
one case seen by me at the end of the fourth week of life. 

In regard to the treatment of either of these displacements of the 

1 Guerin, Gaz. Med., 1851, p. 227. 

2 Seger, Ephem. Nat. Curios., 1677, from Malg., op. cit., p. 410. 

3 Fergusson, System of Surg., 4tli Amer. ed., 1853, p. 203. 



884 CONGENITAL DISLOCATIONS. 

clavicle, we need only remark that a reduction ought to be attempted ; 
and, if practicable, without much confinement to the little patient, it 
should be maintained until the bones have become fixed in their natural 
positions. It is quite probable that this can never be accomplished, at 
least perfectly ; but it will nevertheless be proper always to make the 
attempt. 

§ 8. Congenital Dislocations of the Shoulder. (Upper end of the Humerus.) 

Guerin affirms that he has established the existence of three varieties 
of scapulo-humeral dislocations, namely: — 

1. Dislocations of the head of the humerus downwards; of which 
variety he presented to the Academy a plaster cast taken from a boy 
ten years old. The displacement existed in both arms, but much more 
pronounced in the right than in the left arm. It was due wholly to 
paralysis of the muscles about the joint, and to elongation of the capsule. 

2. Downwards and inwards ; complete upon one side and incomplete 
upon the other, in the same person. The head of each humerus was 
applied against the ribs, and the arms maintained in an abduction almost 
horizontal, under the influence of the retraction of the deltoid muscles. 
" The same case," Guerin remarks, " has been confirmed by Roux." 

3. Subluxation upwards and outwards ; seen on both sides in a foetal 
monster, which was offered to the Academy for examination ; and in one 
arm of a young man fifteen years old, of which Guerin presented a plaster 
cast. " It is characterized by a sliding of the head of the humerus in 
the direction indicated ; this sliding being favored by a corresponding 
displacement of the coracoid and acromion processes." 1 

Malgaigne, who regards " all luxations in consequence of paralysis as 
essentially posterior to birth," will not admit the first example mentioned 
by Guerin ; but, as we stated before, the objections made by Malgaigne 
have failed to convince us of the propriety of rejecting all of this class 
of reported examples. Of the second case, mentioned by Guerin as 
having been confirmed by Roux, Malgaigne declares that he has consulted 
Roux upon this matter, and that he affirms that " he has never seen a 
congenital luxation of the shoulder." 

Robert Smith has met with but two of the forms of congenital luxa- 
tion of the humerus described by Guerin, namely, that in which the 
head of the humerus is displaced forwards, and that in which it is dis- 
placed backwards. Of the first variety he has seen several examples. 

The first was in the person of Alexander Steele, get. 29, who presented 
both a dislocation of the head of the humerus under the coracoid pro- 
cess of the left scapula, and pes equinus in the foot of the left leg. The 
muscles of the arm and shoulder upon that side were feeble and greatly 
atrophied. The humerus was shortened ; its head being of the natural 
size and form, but when the arm hung by the side it dropped so far from 
its socket as to permit the thumb to be placed between the head and the 
acromion process. By pressing the humerus forwards, the finger could 
be placed in the outer part of the glenoid cavity ; and, although the head 

1 GkUirin, op. cit., p. 30. 



CONGENITAL DISLOCATIONS OF THE SHOULDER. 885 

could be moved about thus freely, it seemed naturally to occupy only the 
anterior half of the glenoid fossa. 

Robert Smith's second example of subcoracoid congenital luxation 
was presented in the person of Mr. H., set. 20, the condition of whose 
left shoulder resembled almost precisely that of Mr. Steele. " The de- 
formity had existed from his birth, but became much more obvious and 
striking as he increased in age and stature." 

In the third example the child had attained nearly the age of one year 
before the condition of the limb attracted attention, which was then ex- 
cited, not by the deformity of the shoulder, but by the atrophied condi- 
tion of the muscles of the arm. The child had never complained of pain 
about the joint, nor had he ever met with any accident. No doubt this 
also was an example of paralysis, and it is not improbable that it was 
congenital, but the evidence upon this point is not very conclusive. 
When seen by Mr. Smith, he was nine years old, the shoulder and arm 
presenting the same appearance as in the other cases mentioned. 

The fourth was also subcoracoid and symmetrical, the same deformity 
existing in both shoulders. This was in the person of a female, aet. 21, 
who had been for many years a patient in a lunatic asylum, and who 
died of chronic inflammation of the meninges of the brain. 

Mr. Smith, who himself made the autopsy, first noticed the condition 
of the left shoulder. The muscles were atrophied ; the head of the hu- 
merus could be felt lying under the coracoid process ; the elbow projected 
from the side, but could be readily brought into contact with it. The 
right shoulder presented the same appearance, but the deformity was 
somewhat less, and the head of the humerus was not so directly under- 
neath the coracoid process. 

From the external appearances presented by the two shoulders, Mr. 
Smith did not doubt that these deviations from the natural state of the 
parts were not the result of violence. 

Proceeding to remove the soft parts upon the left side, scarcely any 
trace was found of a glenoid cavity in its natural situation, but imme- 
diately underneath the coracoid process, upon the costal surface of the 
scapula, was formed an oblong socket completely surrounded by a cap- 
sular ligament, which ligament included also that small portion of the 
original socket which remained. The head of the humerus was changed 
in form, being oval, and fitted, in some measure, to both the old and new 
sockets, upon which it seemed to rest alternately. 

Upon the right side, although the condition of the bones was some- 
what different, the characteristic features of the deformity were similar. 

Malgaigne, who quotes Mr. Smith as saying that these dislocations 
must have been congenital, and for no other reason than because they 
were symmetrical, has scarcely done this author justice. Says Mr. 
Smith : " The position of the glenoid cavity, the remarkable form of the 
head of the humerus, the presence of a perfect glenoid ligament, the ab- 
sence of any trace of disease, and the existence of the deformity upon 
each side, all indicate the original nature of the malformation." 

The only example of backward luxation seen by Mr. Smith was also 
symmetrical, and seems to be equally well authenticated. This was in 
the person of a woman named Doyle, set. 42, a lunatic also, who died 



886 CONGENITAL DISLOCATIONS. 

February 8, 1839, in Dublin. She had been a patient in the lunatic 
asylum fifteen years, and was subject to severe epileptic convulsions, 
which ultimately proved fatal. 

Mr. Smith made the autopsy on the day following her death. The 
convolutions of the brain were small and atrophied, as is frequently 
observed in idiots. 

The two shoulders resembled each other so perfectly, both in external 
appearance and in their anatomy, that Mr. Smith has only found it 
necessary to describe particularly the condition of one. 

The coracoid process was remarkably prominent, but the acromion 
w T as not so prominent as in accidental dislocations of the shoulder. 
The head of the humerus could be seen and felt distinctly moving 
with the shaft, upon the dorsal surface of the scapula. On removing 
the integuments, muscles, etc., no trace of a glenoid cavity was found 
in its natural situation ; but upon the external surface of the neck of 
the scapula was a well-formed socket, which received the head of the 
humerus. This socket was covered with a cartilage of incrustation, 
and surrounded by a perfect capsule. The tendon of the biceps arose 
from the top and internal margin of the socket. The form of the 
acromion process was changed ; the capsule smaller than natural ; the 
head of the humerus irregularly oval, its anterior half alone being in con- 
tact with the glenoid cavity ; the great tubercle natural, but the lesser 
was elongated and curved, forming a process of an inch in length, around 
the base of which the tendon of the biceps muscles played. 1 

Gaillard relates the case of a female child, upon whom the left arm 
was discovered to be deformed a few days after birth, and the elbow 
separated from the side. Later, the arm w T as found to be nearly im- 
movable, and only at the end of four years was the dislocation recog- 
nized ; but no attempt at reduction was then made. When sixteen years 
old, she was seen by Gaillard, who found the head of the humerus in 
the infra-spinous fossa. The scapula, clavicle, and arm were preter- 
naturally small ; the forearm, although well developed, could not be com- 
pletely extended nor supinated. 

Despite these unfavorable circumstances, Gaillard determined to make 
an attempt to accomplish the reduction. Four times in the space of eight 
days he submitted the arms to extension made at right angles with the 
body, by means of sixteen-pound weights, the extension being continued 
from twenty to twenty-five minutes, and occasionally his own exertions 
being added to the weights. On the fourth attempt, the head of the 
bone was drawn gradually forwards, and by a rotatory motion it was 
finally made to slip into its socket ; but became immediately displaced. 
The next day Gaillard reduced it anew, and retained it in place one hour. 
Six days later it was again reduced, and, by the aid of bandages, per- 
manently retained in place. The slight pain and swelling which followed 
soon disappeared ; and, by the aid of careful exercise, at the end of two 
years the arm had increased in length, and the patient could use the arm 
and hand so much better than before, as to encourage a hope that the 
recovery would be complete. 2 

1 Robert Smith, op. cit. 

2 Gaillard, Mem. de l'Acad. de Med., 1841, from Malg., p. 569. 



RADIUS AND ULNA BACKWARDS. 887 

Aristide Rodrigue, of Hollidaysburg, Penn., in a letter to the editor of 
the American Journal of the Medical Sciences, gives the following brief 
account of a case of intra-uterine dislocation of the shoulder, compli- 
cated with a fracture of the forearm: — 

" The woman, when about four months gone with child, fell on her 
left side, striking a board, and felt herself much hurt at the time ; at 
the full period she was delivered of a full-groAvn large boy with the fol- 
lowing deformity: dislocation of the humerus into the axilla ; fracture 
of both bones of the forearm of left side, lower third. Dislocation could 
not be reduced ; union of the bones of the forearm by ossific matter com- 
plete ; bones passing each other, and hand at an angle of about 40° ; 
the child did well otherwise ; now, four years old, strong and healthy ; 
humerus has grown nearly apace with the other ; forearm has not, and 
remains short and deformed as at birth ; the hand is of the same size 
with that of the sound side." 1 

I was asked to examine the arm of Joseph Heins, aet. 7, May 12, 
1878, who had a subspinous dislocation of the left humerus. The parents 
stated that the birth of the child was premature, and that she was de- 
lived with forceps, and as a head presentation. On the following day a 
swelling was noticed over the shoulder. On examination I found the 
head of the humerus resting upon the dorsum of the scapula below the 
spine. The scapula is smaller than the opposite scapula, and the arm is 
one and a half inches shorter than the other. The coracoicl process is 
very prominent, and the humerus somewhat rotated inwards. He uses 
the arm nearly as well as the other, and in this respect it is yearly im- 
proving. 

It is difficult to say positively whether this was strictly a congenital 
displacement, or whether it was caused by some violence employed in 
the act of delivery. 

§ 9. Congenital Dislocations of the Radius and Ulna Backwards. 

It is not uncommon to meet with examples of a slight subluxation 
backwards of these bones in feeble and newly-born infants ; which 
condition is probably due to a relaxation and elongation of the capsule. 
It is characterized by a preternatural mobility of the joint, and espe- 
cially by the circumstance that the limb is capable of abnormal exten- 
sion, or flexion backwards, as it is sometimes called. Guerin has seen 
this condition more advanced, the bones of the forearm having actually 
overlapped somewhat upon the lower end of the humerus, so that the 
articular surface of this latter presented itself in the fold of the elbow. 
This was especially observed in a girl of fourteen and a boy of thirteen 
years, and also in the two arms of a foetal monster. 2 

Chaussier relates that a young woman, at the commencement of the 
ninth month of pregnancy, perceived suddenly movements of the foetus so 
violent that she almost lost her consciousness. These movements were 
repeated three times in the space of six minutes, after which everything 



1 Rodrigue, loc. cit., Jan. 1854, p. 272. 

2 GruSrin, op. cit., p. 31. 



888 CONGENITAL DISLOCATIONS. 

returned to its natural order, and the accouchement took place naturally 
and at the usual term. The infant was pale and feeble, and presented a 
complete backward luxation of the radius and ulna. 1 

§ 10. Congenital Dislocations of the Head of the Radius. 

Examples of this luxation have been reported by Dupuytren, Cruveil- 
hier, Sandiforte, Adams, Dubois, Verneuil, Deville, Robert Smith, and 
Guerin, most of which were in the direction backwards, some outwards, 
but only one of them forwards ; some were double, the same deformity 
being presented in both arms, and others were single. In a few exam- 
ples the dislocations were complicated with a consolidation of the radius 
to the ulna, and in others with a deficiency of the ulna or with some 
deformity indicating its congenital origin. 

Of the symmetrical or double dislocation backwards Dupuytren fur- 
nishes the following example, presented to him in 1830, by M. Loir: 
" The abnormal position which the head of either radius had assumed 
was at the back part of the lower extremity of the humerus, beyond 
which it extended for the space of at least an inch. This disposition of 
parts was absolutely identical on the two sides, and had all the characters 
of a congenital affection." 2 

In January, 1866, John Fitzmorris, set. 19, was admitted to the Bel- 
levue Hospital, laboring under a general scrofulous cachexy, in w r hose 
person I found a congenital dislocation of the heads of both radii, out- 
wards. The luxations are complete. The ulna are in place and of natu- 
ral form, but their articulations at the wrist are loose. The same remark 
applies to all the other joints in the body. The power of pronation and 
supination is unimpaired, as well, also, as the power of flexion and 
extension. 

In the example of outward luxation, mentioned by Deville, there was 
an almost complete absence of the ulna, the head of the radius mounting 
upwards more than three centimetres above the level of the articulation. 3 

Guerin, who has described the only example of a forward luxation, 
says it was observed by him in a girl of seven years, and that it was 
symmetrical. The two radii lay in front of the humeri, near the coro- 
nary fosse ttes.* 

§ 11. Congenital Dislocations of the Wrist. 

Gue'rin thinks he has seen three forms of congenital luxation of the 
wrist. First, a dislocation forwards, characterized by a sliding of the 
wrist before the bones of the forearm, and by the projection posteriorly 
of the lower ends of the radius and ulna ; seen in an infant of six 
months, and in two adults. Second, backwards and upwards ; seen 
in a child of six years, and accompanied with an incomplete paralysis 
of all the muscles of the forearm and hand. Third, backwards and 

1 Chaussier, from Malgaigne, op. cit., t. ii. p. 268. 

2 Dupuytren, Injuries and Dis. of Bones, p. 117. 

3 Deville, Bulletins de la Soo. Anat., 1849, p. 153. 

4 Guerin, op. cit., p. 31. 



CONGENITAL DISLOCATIONS OF THE HIP. 889 

outwards ; in a girl of fourteen years, accompanied with incomplete 
paralysis. 1 

Guerin has also seen three examples of dislocation outwards in foetal 
monsters, and one of dislocation inwards, as the result of arrest of 
development. 

Robert Smith believes that the case of simple dislocation of the wrist 
or of the carpus forwards, mentioned by Cruveilhier in his Anatomie 
Pathologique, was an example of congenital luxation ; and he relates 
two other cases equally remarkable which came under his own observa- 
tion. One was in the person of Deborah O'Neil, a lunatic and epilep- 
tic, who died when thirty-six years old. Both upper extremities were 
deformed from birth ; the right presenting an example of dislocation of 
the carpus forwards, and the left of dislocation of the carpus backwards. 
The dissection showed that there had been an arrest of development, 
especially in the bones of the forearm and carpus. The second was in 
the person of a young woman who died of phthisis in the Richmond Hos- 
pital ; the right wrist presenting an example of congenital dislocation of 
the carpus forwards from arrest of development also. 2 

Marrigues describes a very singular congenital displacement which he 
found upon a newly-born infant. The radius and ulna were widely sepa- 
rated below, and in the interspace was lodged the whole of the first range 
of the carpal bones ; the hand being strongly turned inwards. 3 

§ 12. Congenital Dislocations of the Fingers. 

Chaussier found in a foetus the last three fingers of the left hand dis- 
located at the metacarpo-phalangeal articulation. The thighs, knees, and 
feet were also dislocated. 4 

A. Berard speaks of an incurvation backwards of the last two pha- 
langes of the fingers as having been occasionally seen in newly-born chil- 
dren of the female sex ; and Malgaigne adds that he has himself seen a 
woman who had, from birth, all the phalangettes carried backwards to an 
angle of 135°, leaving the heads of the phalanges projecting forwards 
under the skin. 5 

Robert has seen, in a girl six years old, a congenital lateral luxation 
of the phalangette of the index finger, which was inclined outwards at 
an obtuse angle. The external condyle of the lower extremity of the 
proximal phalanx was slightly atrophied, and the internal presented a 
corresponding projection. Robert cut the internal lateral ligament by a 
subcutaneous incision, but without any favorable result. 6 

§ 13. Congenital Dislocations of the Hip. 

Dupuytren thought that double dislocations of the hip-joint, as congen- 
ital accidents, were more common than single dislocations, but in the ex- 

1 Guerin, p. 717. 2 R. Smith, op. cit., pp. 238, 251. 

3 Marrigues, Malgaigne, from Journ. de Med., t. ii. 1775, p. 31. 

4 Chaussier, Malgaigne, op. cit., t. ii. p. 751. 

5 Berard, Malgaigne, op. cit., p. 773. 

6 Robert, from Malgaigne, op. cit., p. 773. 
57 



890 CONGENITAL DISLOCATIONS. 

perience of Pravaz the rule has been reversed, he having met with but 
four double dislocations in a total of nineteen. 

Congenital dislocations of the femur have been noticed much oftener 
in females than in males. Of forty -five examples mentioned by Dupuy- 
tren and Pravaz, only seven or eight were males. 

They may be complete or incomplete. Of the complete luxations, four 
varieties have been noticed. 

Upwards and backwards, upon the dorsum ilii. This variety is by far 
the most common. 

Upwards and forwards ; the head of the femur resting upon the emi- 
nentia ilio-pectinea. 

Downwards and forwards into the foramen thyroideum ; of which 
variety Chaussier alone mentions one example ; but Delpech found in 
an infant, born paralytic, the head of the femur lodged habitually near 
the foramen thyroideum. 

Directly upwards ; seen by Guerin, Pravaz, and others ; the head of 
the femur being placed immediately without the anterior inferior spinous 
process of the ilium. 

Gue'rin has observed, moreover, a single variety of subluxation ; char- 
acterized by the incomplete displacement of the head of the femur in the 
direction upwards and backwards, so that it rested upon the edge of the 
cotyloid cavity : " observed often in newly born children, and with those 
in whom the muscular dislocations are effected spontaneously after birth." 

Through the courtesy of Dr. Davis, of this city, I was permitted, in 
March, 1865, to see a child, the daughter of a gentleman residing in Victor, 
Monroe Co., N. Y., who was born in 1860, with dislocation of both knees 
and both hip-joints. The legs at the time of birth were doubled forward 
upon the thighs, the heads of the tibias resting upon the front of the 
femurs, one inch above the condyles, the thighs being at right angles with 
the body and the feet touching the abdomen. The knees w r ere drawn 
closely together. The dislocation of the heads of the femurs was not 
at this time recognized. By constant pressure Dr. J. B. Palmer had 
succeeded, at the end of one year, in restoring the leg to position, the 
thighs remaining flexed ; but when two years old she began to walk, with 
her body bent forwards. The displacement of the hip-bones was then 
first discovered. When four years old the sartorius and tensor vaginse 
femoris were severed, but with very little benefit. At the time of my ex- 
amination she was five years old. The thighs were still flexed and ad- 
ducted ; by pressure upon the knees the femurs could be slid upwards and 
backwards upon the ilium one inch ; on rotating the femurs the trochanters 
were observed to move upon a very short radius, indicating the entire 
absence of head and neck. She walked with the gait peculiar to these 
conditions. 

Both Delpech and Gr.erin have called attention to two varieties of what 
the latter terms pseudo-luxations ; of which the first simulates a disloca- 
tion upwards and backwards, and the second a dislocation downwards and 
forwards. In these examples, the extreme adduction or abduction of the 
thighs might lead to a belief that the bones were dislocated, when in fact 
the abnormal position of the limbs is due only to muscular contraction, 
without actual articular displacement. 



CONGENITAL DISLOCATIONS OF THE HIP. 891 

In the remarks which follow we shall have special reference to that 
form of congenital dislocations of the femur in which the head of the bone 
rests upon the dorsum ilii, as being that which will be presented in a vast 
majority of cases, and which, characterized by the same general pheno- 
mena, may be regarded as typical of all the others. 

Symptomatology. — First. When the dislocation is double. 

In these examples the deformity is often found to be symmetrical; the 
opposite limbs being of precisely the same length, and in the same relative 
positions; a circumstance which, when it exists, may render the diagnosis 
more difficult, or may cause it to be for a long time entirely overlooked. 
It is in such cases especially that the deformity is not usually discovered 
until the child begins to walk. 

The first circumstance which w T ould naturally arrest our attention, if 
the person who is the subject of this double dislocation is stripped and 
placed erect before us, is the great apparent length of the arms and of 
the body in comparison with the lower extremities. We may next ob- 
serve that the great trochanters are carried upwards and backwards, so 
as to make a remarkable projection in this direction ; the lumbar portion 
of the spinal column is thrown very much forwards and the dorsal portion 
backwards. The thighs incline inwards, so as almost to cross each other; 
the whole of the lower extremities are imperfectly developed and feeble ; 
the toes are generally pointed directly forwards, or they may be noticed 
to turn inwards. 

When the person stands, and his limbs are not in motion, the heel is 
usually brought down fairly to the floor ; but in walking, and especially 
in the attempt to run, he touches only the balls and toes of his feet. 
" When they are about to walk," says Pravaz, " we see them lift them- 
selves upon the points of the feet, to incline the superior part of the trunk 
toward the member which is about to support the weight of the body, and 
to lift the other from the ground with an effort, in order to carry it for- 
wards. At this moment one of the trochanters, that which corresponds 
to the column of sustentation, appears to approach the iliac crest more 
nearly than when the patient is standing upon his two feet." In conse- 
quence of which mobility of the thigh-bones, the patient assumes a pe- 
culiar waddling gait, which is not only ungraceful, but exceedingly 
fatiguing. 

The difficulty of progression is, however, very variable in different 
persons. Sometimes the patient requires no aid whatever, and at other 
times he cannot walk without assistance. Generally it increases with 
age. It is especially deserving of notice that in rapid progression the 
mobility of the heads of the femurs is appreciably less than in slow 
progression, which is explained by the more constant and vigorous con- 
traction of the muscles about the joint, when the motions of the limb 
are rapid. 

In the recumbent posture, the thighs may be drawn down easily to 
almost their natural positions. The only exception to this rule, accord- 
ing to Carnochan, " is when the head of the femur has escaped from the 
natural capsule in which it was originally inclosed, and a new socket has 
been formed upon the dorsum of the ilium." 



892 CONGENITAL DISLOCATIONS. 

Abduction is performed with difficulty ; adduction and rotation, espe- 
cially inwards, being less restricted. 

Second. When the dislocation is only upon one side. 
In these cases the symptoms are essentially the same as in the double 
dislocation ; with only such slight differences and peculiarities as would 
naturally suggest themselves to the surgeon, and which will not, there- 
fore, demand from us a special consideration. 

Pathology. — The head of the femur is sometimes merely changed in 
form and consistence, the neck also undergoing corresponding alterations 
in its size, form, direction, etc. : at other times the head is absent alto- 
gether, and with it a considerable portion or the whole of the neck has 
disappeared. 

The pelvic bones are usually more or less deformed. The acetabulum 
may be entirely deficient, or it may present itself as an irregular bony 
protuberance, without cartilage, fibro-cartilage, or ligaments. Some- 
times it exists as an oval or triangular cavity, which is expanded at its 
superior and posterior margin into a distinct fossa, where the head of the 
femur, descending from the dorsum ilii, occasionally rests. A new cavity 
is formed usually upon the. side of the pelvis, which is shallow and with- 
out an elevated margin, or it may be deeper, and more complete in its 
construction by the addition of an osseous border. In either case, the 
new socket is often lined with a true periosteum and synovial membrane; 
but not unfrequently it is unprotected by any soft tissue, the surface be- 
ing hard and polished like ivory. 

The head of the femur, having escaped from its original capsule, 
through a button-like opening, rests in this socket constantly. In still 
other examples the head of the femur remains within its capsule, and may 
be observed to play backwards and forwards between the two sockets ; 
or the head and neck being absorbed, and the capsule remaining entire, 
the latter is converted into a long narrow sac, somewhat contracted in 
its centre ; or finally into a firm ligamentous cord, which being attached' 
to the stunted upper extremity of the femur, limits its motions in the 
direction of the crest of the ilium. In this case no new socket is formed. 
A portion of the pelvi-femoral muscles are contracted, in consequence 
of an approximation of their points of origin and insertion, and remain- 
ing in a state of comparative, if not absolute, inertia, they become atro- 
phied, or pass into a condition of fatty degeneration; while other muscles, 
in consequence of the increased labor which they have to perform, be- 
come hypertrophied, or degenerate into a fibrous tissue. 

Treatment. — Says Dupuytren : "Of what possible utility can it be to 
practice extension of the lower extremities in these cases, even supposing 
the limbs could be thus brought to their natural length ? Is it not evi- 
dent that the head of the femur, finding no cavity fitted to receive and 
hold it, would, when abandoned to itself, resume its former abnormal 
position ? There is something more rational and feasible in adopting a 
palliative course of treatment. When we call to mind the natural prone- 
ness which the heads of thigh-bones have to ascend to the external iliac 
fossse, and that this tendency is partly due to the superincumbent weight 
of the body, and in part to muscular action, a just conception may be 
formed of the indications on which the employment of palliative reme- 



CONGENITAL DISLOCATIONS OF THE HIP. 893 

dies should be founded. The object should be to relieve the lower limbs 
of the superincumbent weight on the one hand, and on the other to 
moderate the muscular action. Both of these indications are in part 
fulfilled by repose ; and the attitude most conducive to this effect is the 
sitting posture, in which the weight of the upper part of the body is not 
transmitted to the lower extremities, but is centred in the tuberosities of 
the ischia. Therefore, laboring persons afflicted with this infirmity should 
be recommended to adopt a sedentary occupation, as a calling which re- 
quires much standing and walking about would dangerously aggravate 
their deformity. Yet one would scarcely be willing to condemn such 
individuals to perpetual repose ; and to avoid this it is necessary to dis- 
cover some means for diminishing the inconveniences which attend the 
upright posture, the act of walking and other exercises. Experience 
has taught me hitherto bat two methods of obtaining this important ob- 
ject : the first consists in the daily employment of a perfectly cold bath, 
in which all the body should be immersed for the space of three or four 
minutes, the head being protected by an oiled-silk cap ; the water may 
be fresh or salt ; and the only precautions necessary to take are to avoid 
bathing when the body is in a state of perspiration, or when the cata- 
menial discharge is present. These baths have a local, as well as general, 
tonic effect. The second method consists in the constant use, at least 
during the day, of a belt, which embraces the pelvis, fitting closely over 
the great trochanters, and keeping them at a constant height, so as to 
bind the parts together, and prevent that continual unsteadiness of the 
body which results from the loose connections of the heads of the thigh- 
bones. For the proper fulfilment of these indications, certain precau- 
tions are necessary in the construction of this cincture ; in the first place, 
it should occupy the narrow interval between the crest of the ilium and 
great trochanters, completely filling this space, and therefore being about 
three or four fingers' breadth, according to the age and size of the patient. 
It should further be well padded with wool or cotton, and covered with 
doeskin, so that it may not abrade the parts to which it is applied ; and 
there should be a piece let in on either side, so as to receive and support 
the trochanters without entirely covering them ; it should be buckled be- 
hind, and padded straps be carried under the thigh, and across the tuber- 
osity of the ischium, on either side, to prevent the zone from slipping up. 
I do not mean to assert that I have ever succeeded in completely getting 
rid of the inconveniences of congenital dislocations of the thi^h-bones, 
but I have prevented their increasing, and have rendered supportable 
what I could not cure. The testimony of some patients to the value of 
this treatment has been of a most unequivocal character ; for being wor- 
ried by the pressure of the belt, they have laid it aside, but have speedily 
restored it again, as they found that without it they had neither a sense 
of firmness in the hip, nor confidence in walking." 

In relation to which opinions the same excellent writer subsequently 
made the following candid admission : " I at first thought that no benefit 
would be derived in these cases from the employment of continual trac- 
tion on the lower extremities, for reasons already stated ; but the expe- 
riments of MM. Lafoncl and Duval tend to throw some doubt on the 
correctness of this conclusion. These distinguished practitioners tested 



894 CONGENITAL DISLOCATIONS. 

the influence of extension, in their orthopedic institution, on a child eight 
or nine years of age, who was the subject of double congenital disloca- 
tion of the hip ; after the uninterrupted employment of this treatment 
for some weeks, I satisfied myself that the limbs had resumed their 
natural length and direction; but I was not a. little astonished to find 
that, after extension had been persisted in for three or four months con- 
tinuously, the greater part of the beneficial results remained for several 
weeks undiminished. It would be idle, it is true, to generalize on this 
single case ; but as an isolated example of the utility of extension it is 
interesting, and it may be the forerunner of more important results." 1 

Since which time Humbert and Jacquier, who, as well as Duval and 
Lafond, confined themselves to the treatment of deformities, claim to 
have met with equal success in the management of these cases by exten- 
sion alone ; and, still more lately, Guerin, of Paris, and Pravaz, of 
Lyons, by the adoption of the same general principle more or less modi- 
fied, have added new triumphs, and greatly enlarged its application. 

The means recommended and practised by Gue'rin are : first, pre- 
paratory extension destined to elongate the muscles as much as possible ; 
second, subcutaneous section of the muscles which mechanical extension 
has not sufficiently elongated ; third, extension of the ligaments, and 
even, if extension does not suffice, their subcutaneous section ; fourth, 
manoeuvres destined to effect reduction ; fifth, treatment designed to con- 
solidate the reduction, and consisting in the application of the apparatus 
proper to maintain the extension and separation of the divided tissues, 
and to retain the head of the femur in its place ; finally, in the gradual 
execution of movements proper to complete the coaptation of the sur- 
faces, and to establish, little by little, the physiological movements of 
the joint. 

Other surgeons have confined their efforts to the reduction of the dis- 
location, and they have, consequently, abandoned all those cases in which, 
owing to the complete absence of the natural socket, or to the want of 
sufficient mobility in the limb, the reduction was deemed impossible ; but 
Guerin has gone a step farther, and has sought to establish a new socket 
upon some point of the pelvic bones as near as possible to its natural 
articular fossa. " The means which I adopt," says Guerin, " are based 
upon a recognition of the processes which nature employs for the attain- 
ment of the same purpose, and of which mine are but an imitation. I 
have shown that the essential condition of the formation of artificial 
cavities is perforation of the articular capsule, and the placing in con- 
tact of the luxated extremity with an osseous surface, and that the con- 
dition of the maintenance of this abnormal rapport is the intimate ad- 
herence of the borders of the rent with the circumference of the new 
cavity. Now it appeared to me that art could realize, in all points, the 
conditions which preside at the spontaneous formation of artificial joints. 
To this end I commence by practising under the skin, and at the point 
corresponding to that where it is most convenient to fix the luxated ex- 
tremity, scarifications of the capsule, down to the bone to which it is 
attached. By this means the dislocated extremity is placed in immediate 

1 Dupuytren, op. cit., pp. 176-178. 



CONGENITAL DISLOCATIONS OF THE HIP. 895 

contact with the bony surface upon which it reposes. It makes upon 
this point a beginning of the work of organization resulting from the 
adhesion and fusion of the scarified points with the corresponding points 
of this surface. Then, in order to circumscribe and imprison the luxated 
extremity, in this place of election, I practise all about deep scarifica- 
tions, which tend to excite the same work of organization and to estab- 
lish fibro-cellular adhesions between the incised borders of the capsule 
and the contiguous bony surfaces. 

" Finally, when the fibro-cellular adhesions are supposed to be suffi- 
ciently solid to resist the movements of the new articulation, I provoke, 
little by little, the development of the cavity destined to embrace the 
luxated extremity by the means which nature herself employs in analo- 
gous circumstances ; that is to say, by circumscribed and frequent move- 
ments of this articulation." 1 

The treatment ought to be commenced as early as possible, no exam- 
ples of success having been recorded in persons over fifteen years of age ; 
while the youngest child whose treatment is reported as successful was 
three years of age. 

For the purposes of making the requisite extension, and of maintaining 
the bone in place, Pravaz (who does not, however, adopt Guerin's prac- 
tice of establishing for the head of the bone a new socket, but only seeks 
to reduce and maintain it in its old socket) has invented several forms of 
apparatus adapted to the different stages of progress in the treatment. 
Heine, of Cannstadt, Guerin, and others, have also suggested special con- 
trivances for the same purpose ; but no surgeon who understands fully 
the principle upon which the cure is supposed to be accomplished, will 
be at a loss for apparatus suitable for making the necessary extension, 
or for maintaining the reduction when once it has been, effected. 

The length of time required for the completion of a cure, where a 
cure is possible, must vary according to the age and health of the patient, 
and according to the pathological condition of the joint, and may be 
found to extend from a few months to one or more years. It is unneces- 
sary to say that where the accomplishment of the cure demands a period 
of several years, the treatment must be intermittent and greatly varied, 
so as to suit all the changing circumstances in the condition of the 
patient. 

Finally, if after a fair trial we fail to accomplish a cure, or if the condi- 
tion of the child will not warrant even the attempt, we ought as far as 
possible to seek to prevent an increase of the deformity by such means 
as our ingenuity may suggest, or by such judicious appliances and gene- 
ral management as we have seen recommended by Dupuytren. 

South says that he has seen one case of double dislocation in which 
the walking was at first extremely difficult, but from the fifteenth year 
and onwards the patient so improved, that at the twentieth year scarcely 
any trace of the peculiar gait could be discovered. 2 

1 Guerin, op. cit., pp. 81-83. 

2 South, Note to Chelius, op. cit., vol. ii. p. 245. 



896 CONGENITAL DISLOCATIONS 



§ 14. Congenital Dislocations of the Patella. 

Palletta found a dislocation of the patella in the cadaver of a young 
man, which he supposed to be congenital. 1 Michaelis has reported two 
cases; one in a young man of seventeen years, and the other in a girl 
of fourteen, each of whom affirmed that it had existed from birth. 2 
Both of these examples presented themselves at the hospital on account 
of hydrarthrosis of the knee-joints, and Malgaigne, who had himself 
seen a similar case, is disposed to regard them all as examples of path- 
ological rather than congenital luxations. Periat reports a case in which 
the dislocation was only produced by walking, and in relation to the 
authenticity or pertinence of which Malgaigne seems also to entertain a 
doubt. 3 

South says that he has seen a congenital dislocation on both legs, in 
an aged man. The patellae rested entirely upon the outer faces of the 
external condyles, leaving the front of the knee-joint completely un- 
covered. When the limbs were extended the patellae could be easily 
made to resume their natural positions, but on the patient's making the 
slightest movement they were again displaced. The knees were very 
much inclined inwards, the feet outwards, and his gait was difficult and 
unsteady. 4 

Dr. Samuel G. Wolcott, of Utica, N. Y., informs me that he has under 
observation a case similar to the one reported by South, in a healthy 
and otherwise well-formed and well developed boy, set. 4. " When the 
legs are flexed the patellae slip outwards upon the external condyles of 
the femurs, and on extending the legs the patellae resume their positions 
in front of the knee-joints. This occurs at every step he takes. The 
knees are strongly inclined inwards, and the feet outwards. His step is 
very insecure, and if accidentally he hits his feet or legs against any- 
thing in walking, he invariably falls." 

The most remarkable example, however, has been reported by Dr. E. 
J. Caswell, of Providence, R. I., inasmuch as no less than five members 
of the game family have double congenital dislocations of the patellae. 
The man who was the subject of Dr. Caswell's special examination is 
43 years old, and possessed of a good constitution. The patellae lay 
upon the outer condyles, and are movable, performing their functions 
nearly as well as if placed in their proper positions. He walks without 
difficulty upon level ground, or upon an ascending plane, but great caution 
is required in descending. The right patella is longer and less movable 
than the left, and the muscles of both of his lower extremities are small. 

" In addition to his labor as an operative, he cultivates a small farm." 
Dr. Caswell examined his son and found the same malposition, but less 
marked than in the case of the father. The father then stated that his 
own father, his sister, and the son of his half brother by the same father, 
had a similar deformity. 5 



1 Palletta, Exercitationes Pathologic*, p. 91. 

2 Michaelis, Rev. Med.-Chirurg., torn. xv. p. 56. 

3 Periat, Malgaigne, op. cit., torn. ii. p. 932. 

4 South, Note to Chelius, op. cit., vol. ii. p. 247. 

5 Caswell. Amer. Journ. Med. Sci., July, 1865. 



CONGENITAL DISLOCATIONS OF THE KNEE. 897 

§ 15. Congenital Dislocations of the Knee. 

The head of the tibia has been found, at birth, dislocated forwards, 
backwards, inwards, outwards, inwards and backwards, outwards and 
backwards, and simply rotated inwards. 

Most of these luxations were incomplete ; and of them all, the dislo- 
cation forwards has been observed much the most often. 

A subluxation forwards of the head of the tibia has been seen by 
Guerin in a foetal monster, accompanied with extreme retraction of the 
extensor muscles of the leg. 1 Cruveilhier has dissected a foetus affected 
with a similar subluxation. 2 

In these examples the displacement forwards at the articular surface 
was but slight, and. the anterior flexion of the limb inconsiderable ; but 
when the dislocation is complete, or nearly so, the deformity is in all 
respects very much increased ; as the following examples will illustrate. 

Dr. D. H. Bard, of Troy, Vermont, has reported an example of com- 
plete anterior luxation of the tibia, seen by himself, in a new-born infant. 
The leg was found drawn forwards upon the thigh at an acute angle, so 
that the toes pointed toward the face of the child, and the bottom of the 
foot was directed forwards. By the application of moderate force, the 
limb could be straightened and even flexed completely. These motions 
inflicted no pain. It was especially noticed that in bringing down the 
leg from its position of extreme anterior flexion (extension) more force 
was required in the first part of the manoeuvre than in the last ; and 
that if, having brought the leg down, it was left to itself, it immediately 
resumed the abnormal position, moving at first slowly, but after a time 
much more rapidly. 

The limb was confined by bandages for a short time, and it did not 
afterwards show any disposition to return to its unnatural position. The 
child did well, and when it began to use its legs, no difference could be 
discovered between them. 3 

J. Youmans, of Portageville, N. Y., reports a similar case which 
occurred in his own practice. A healthy woman was delivered, on the 
16th of August, 1859, of a full-grown female child, whose left knee was 
so completely dislocated that the toes rested upon the anterior part of 
the thigh near the groin. Dr. Youmans immediately took hold of the 
limb and brought it to its natural form, but as soon as he relinquished 
his hold, it flew back to its original position. Having again straightened 
the leg it was retained in place easily by two pieces of whalebone tied 
upon each side of the thigh and body. Some soreness and swelling 
ensued, and it was some weeks before the splint could be safely removed. 
At the time of the report, October 11, 1860, the child was using the 
limb with as much freedom and dexterity as other children of her own 
age. 

In the report particular attention is called to the disposition on the 

1 Guerin, op. cit., p. 33. 

2 Cruveilhier, Atlas de l'Anat. Patholog., 2e livr., pi. 2. 

3 Bard, Amer. Journ. Med. ScL, Feb. 1835, p. 555, from Bost. Med. ani Surg. 
Journ., Nov. 26, 1834. 



8ir>8 CONGENITAL DISLOCATIONS. 

part of the limb to resume its unnatural position with a spring, showing 
contraction of the anterior muscles of the thigh; to the fact that the 
patella of this knee was smaller than the other, and that the skin on the 
front of the knee was wrinkled as it is usually back of the knee in fat 
children. 1 

I have mentioned a case of congenital forward dislocation of both 
tibiae which came under my observation, in the section on congenital 
dislocations of the hip, and I have recently seen a case of congenital 
subluxation of both tibiae backwards, occasioned by contraction of the 
hamstrings. Section of the muscles restored the bones nearly to their 
normal position. 

Chatelain was consulted in relation to a similar case, in which the 
restoration of the limb to its natural position was also easily effected, 
and by means of three metallic splints, applied during about fifteen days, 
the cure was consummated. Chatelain directed, however, that the leg 
should be kept flexed upon the thigh eight days longer. 2 

Kleeberg found a child with the leg so much flexed forwards (extended) 
upon the thigh that the popliteal region became the lowest point of the 
limb ; in front and above the articular extremity of the tibia could be 
felt, and the condyles of the femur made a corresponding projection 
behind into the popliteal space. This was plainly an example of com- 
plete luxation ; and, contrary to what was observed in Bard's case, 
flexion of the limb backwards was difficult and painful. 

The treatment was commenced by securing the limb in a straight 
position by means of a splint and roller; subsequently, Kleeberg car- 
ried the limb back to an obtuse angle, and finally, it was kept eight 
days in a position of extreme flexion. A complete cure was said to 
have been accomplished in about two weeks. 3 

Gruerin has seen a subluxation backwards, accompanied with a slight 
rotation of the head of the tibia outwards, in a girl fourteen years old ; 
and which, he affirms, was congenital, characterized by a permanent 
flexion (backwards) of the leg upon the thigh, and a sliding of the con- 
dyles of the tibia backwards. 

This girl was under Guerin's treatment, but with what result is not 
stated. 4 

Chaussier found both tibiae displaced backwards in an infant otherwise 
deformed. 5 

Robert speaks of an example of lateral subluxation in a man, which 
had existed from birth. The right knee was thrown inwards, and the 
left outwards. 6 

Guerin " operated" publicly upon a child, two years old, who had a 
congenital dislocation of the head of the tibia backwards and inwards, 
accompanied with a slight rotation of the leg inwards. 7 In what man- 
ner he operated, and with what result, he does not inform us. 

1 Youmans, Bost. Med. and Surg. Journ., Oct. 25, 1860, vol. lxiii. p. 250. 

2 Chatelain, Bibliotheque Med., torn. lxxv. p. 85. 

3 Kleeberg, Malgaigne, op. cit., p. 983. 4 Guerin, sur les Lux. Congen., p. 33. 
5 Chaussier, Malgaigne, op. cit., p 884. 6 Robert, Malg., op. cit., p. 985. 

7 Guerin, sur les Lux. Congen., p. 33. 



CONGENITAL DISLOCATIONS OF THE TOES. 899 

The same writer speaks of a subluxation backwards and outwards, 
with rotation in the same direction, a deformity which, he affirms, is 
very frequent, and which appears especially after birth, although the 
causes which produce it have given their first impulse during intra- 
uterine life. 

The case quoted from Robert, by Malgaigne, as an example of dis- 
location inwards, seems to have been rather a case of semi-rotation of 
the articular surfaces, the inner condyle being thrown back into the 
popliteal space, while the outer condyle still retained its natural posi- 
tion. 

§ 16. Congenital Dislocations of the Tarsal Bones. 

Under this general term may be included all those varieties of sub- 
luxation of the several bones which compose the tarsus, and which are 
known as examples of talipes or club-foot ; such as tibio-astragaloid 
luxations, astragalo-scaphoid, calcaneo-astragaloid, calcaneo-cuboid, etc. 

Although these deformities may properly enough claim a place in a 
chapter on congenital dislocations, they have so long been the subjects 
of special treatises as to justify their exclusion from the present volume. 

§ 17. Congenital Dislocations of the Toes. 

Observed occasionally at the metatarso-phalangeal articulations ; the 
articular facets of the first phalanges suffering a subluxation upwards, 
or laterally upon the corresponding metatarsal bones. 

Guerin has noticed especially a congenital lateral subluxation of the 
great toe. 1 

1 Guerin, op. cit., p. 34. 



INDEX. 



PART I. FRACTURES. 



ABSCESS in fracture of the sternum, 
184 
Acetabulum, 382 
Acromion process, 226 
Amesbury's thigh splint, 444 
Anaesthetics, use of, in diagnosis, 37 
Anatomical neck of humerus, 234 
Anaplasty in fractures of the septum na- 

rium, 108 
Anchylosis after Colles's fracture, 317 

after fractures of elbow, 297 

after fracture of patella, 513 

anchylosis of knee, 494 
Apparatus immobile, 62 

in fractures of the leg, 546 
Arytenoid cartilages, fractures of, 153 
Asymmetry of long bones, 442 
Astragalus, 564 
Atlas, 178 
Axis, 174 

and atlas, 178 



BADLY united fracture of leg, 561 
Barton's bran dressing, 72 

bandage for fractured jaw, 143 

trephining vertebrae, 162 

fracture of lower end of radius, 313 
Base of acetabulum, 382 

of condyles of femur, 484 

of condyles of humerus, 271 
Bauer's wire splints, 555 
Bean, lower jaw apparatus, 138 
Bending of bones, 84 
Biceps, displacement of long head, 674 

rupture of, 674 
Bigelow, stellate fracture of lower end of 
radius, 310 

rim of acetabulum, 389 
Boardman, fracture of zygoma, 118 
Body of the scapula, 220 
Bodies of the vertebrae, 165 
Bond's elbow splint, 278 

radius splint, 321 
Bosworth, Frank, tracheotomy in fracture 

of lower jaw, 122 
Box for leg, 557 
Boyer's thigh splint, 444 
Brainard, perforator, 81 



Buck, lower jaAv, 133 
thigh splint, 472 
Burge, patella, 520 



CALCANEUM, 563 
Carpal bones, 366 
Cartilages of the ribs, 191 
Cervical ligaments, strain of, 171 

vertebrae, bodies of five lower. 169 
axis, 174 
atlas, 178 
atlas and axis, 178 
Children, fracture of femur, 481 
Chronic rheumatic arthritis, 410 
Clark, fracture of humerus, 264 
Clavicle, 193 

partial fractures, 219 
Cline, trephining vertebrae, 161 

fracture of atlas, 178 
Coates, fracture bed, 474 

bran dressings, 72 
Coccyx, 390 
Colles's fracture, 305 
Comminuted fracture, 69 
Common signs of fracture, 84 
Compound fractures, 69 
forearm, 365 
thigh, 483 
patella, 527 
tibia and fibula, 546 
Concussion of spinal marrow, 171 
Condyles of humerus, 282 
internal, 291 
external, 294 
base, 271 

base and between condyles, 279 
of femur, 491 

external, 491 
internal, 493 
base, 484 

between condyles, 494 
Congenital, 31, 259, 529 
Cooper, Sir Astley, fracture of olecranon 
process, 351 
neck of femur within capsule, 403 
patella, 518 
Coracoid process, 230 



Coronoid process of ulna, 337 






902 



INDEX — FRACTURES. 



Cotyloid cavity, 382 

Covers to splints, 50 

Crandall, extension, fracture of leg, 553 

Cricoid cartilage, 152, 154 

Crosby, femur, external condyle, 492 



DANIELS'S fracture-bed, 474 
Deformities of legs, 561 
Delayed or non-union, 73 
Dennis, F. S., fracture of inferior maxilla, 

127 
Denticulated fractures, 28 
Dextrin, 62 
Diagnosis, general, 33 
Dieffenbach, tenotomy in fracture of ole- 
cranon process, 354 
Dislocation of humerus, differential diag- 
nosis, 250 
Division of fractures, general, 27 
Dorsal vertebrae, 168 
Dorsey, fracture of patella, 518 
Dugas, sign of dislocation of humerus, 

250 
Dupuytren's case of fracture of a dorsal 
vertebra, 168 
body of a lower cervical vertebra, 

169 
dressing for fracture of fibula, 537 



ELBOW splint, Physick's, 277 
Kirkbride's, 277 

Rose's, 277 

Welch's, 277 

Bond's, 278 

the author's, 278 
Else, fracture of axis, 174 
Emphysema in fracture of ribs, 189 
Epicondyle of humerus, external, 290 

internal, 283 
Epiphyseal separations, 29 

acromion, 227 

humerus, upper end, 241 
lower end, 272 

olecranon process, 354 

femur, upper end, 397 
lower end, 496 

trochanter major, 428 

tibia, 529 
Epiphyses, sternum, 179 

scapula, 228 

humerus, 242 

radius, 332 

ulna, 341 

os innominatum, 374 

femur, 392 

tibia, 529 

fibula, 533 
Epitrochlea, 283 
Etiology, general, 29 
Eve, non-union of ribs, 188 

patella, 527 
Exciting causes, general, 30 
Experiments on bending, 84 

on partial fractures, 90, 93 



External epicondyle of humerus, 290 
condyle of humerus, 294 
femur, 491 
Extension of thigh by adhesive plaster, 
473, 477 



FANNING, N., humerus, 260 
Fauger, Colles's fracture, 321 
Felt splints, 59 
Femur, 392 

neck, within capsule, 394 

upper epiphysis, 397 

neck, anatomy of, George K. Smith, 
408 

differential diagnosis, 423 

without capsule, 419 

trochanter major and base of neck, 
427 

epiphysis of trochanter major, 428 

shaft, 430 

lower third, 484 

measurement of, 441 

in children, 481 

external condyle, 491 

internal condyle, 493 

between condyles, 494 

base, and between the condyles, 494 

delayed and non-union, 497 

separation of lower epiphysis, 496 
Fibroid union, 497 
Fibula, 533 
Fingers, 370 
Fissures, 96 

neck of femur, 393 
Fitch, fracture of lower jaw, 142 
Flagg's thigh apparatus, 449 
Floating cartilages in knee-joint, 329 
Forearm, 298 

Four-tailed bandage for broken jaw, 144 
Fractures, 27 

general etiology, 29 

general semeiology and diagnosis, 33 

repair of fractures, 38 

general prognosis, 44 

general treatment, 52 

delayed union, 73 

incomplete, 84 
Fracture beds, 474 

Jenks, 474 

Hewson, 474 

Barton, 474 

Coates, 474 

Daniels, 474 

Burges, 474 

Crosby, 475 
Fracture-box, 557 



GANGRENE, after use of immovable 
apparatus, 56, 461, 483 
after fracture at base of condyles of 

humerus, 275 
Dupuytren's cases after fracture of 

radius, 323 
Robert Smith's cases, 330 



INDEX — FRACTURES. 



903 



Gangrene — 

Norris, 331 

after fracture of forearm, 357 

patella, 517 

leg and thigh, from tight roller, 52, 
331, 458, 461, 483, 532, 545 
General division of fractures, 27 

etiology of fractures, 29 

semeiology of fractures, 33 

prognosis of fractures, 44 

treatment of fractures, 59 
Gibson, inferior maxilla, 142 
Gilbert, apparatus for broken femur, 453 

leg, 553 
Glenoid cavity of scapula, comminuted, 

225 
Granger, fracture of epicondyle, 285 
Greater tubercle of humerus, 239 
Gum-shellac splints, 52 
Gunshot fractures, 569 

treatment in, 572 
Gurlt, 29 
Gutta-percha splints, 60 



HARRIS, separation of upper maxillary 
bones, 113 
Harrold, lumbar vertebra?, 168 
Hartshorne, Edward, clavicle, 208 
Hartshorne, Joseph E., thigh apparatus, 

453 
Hays, radial splint, 321 
Hayward, lower jaw, 133 
Head of radius, 301 

and anatomical neck of humerus, 234 
Head and neck of humerus, longitudinal 

fracture, 239 
Hewson, fracture-bed, 474 
Hodge, thigh splint, 454 
Hodgen's fractare-cradle, 574 

wire, suspension splint, 448 
Hodges, head of radius, 301 
Horner, thigh apparatus, 452 
Hot water, 72 
Humerus, 233 

anatomical neck, 234 

head and neck, 234 

tubercles, 238 

longitudinal fracture of head and 
neck, 239 

surgical neck, 241 

upper epiphysis, 241 

differential diagnosis, 250 

shaft, 259 

lower epiphysis, 271 

base of condyles, 271 

with splitting of condyles, 279 

condyles, 291 

internal epicondyle, 283 

external epicondyle, 290 

internal condyle, 291 

external condyle, 294 

delayed union, 261 

dislocation of, 250 
Hutchinson, leg splint, 551 



Hyde, F. E., fractures of femur, 392, 393, 

414, 419 
Hyoid bone, 147 



TLIUM, 378 

JL Immovable apparatus, 62 
leg, 546 
thigh, 455 
Impacted fractures, 28 

head and neck of humerus, 234 

tubercles, 230 

neck of femur within capsule, 397 

without the capsule, 419 
radius, 310, 316 
Incomplete fractures, 84 
Inferior maxilla, 121 
Interstitial absorption of neck of femur, 

410 
Internal condyle of humerus, 291 

femur, 493 
Interdental splints, 135 
Intrauterine fracture, 31, 259, 529 
Ischium, 377 

JACKSON, acromion process, 227 
Jenks, fracture-bed, 474 
Johnson, neck of femur, 406 



EY. lumbar vertebra?, 168 

Kingsley, fracture of lower jaw, 141 



LANGE, separation of lower epiphysis of 
humerus, 272 
Larynx, fracture of, 152 
Lausdasle, patella, 519 
Lente, fracture of dorsal vertebra, 168 
femur, 455 
non-union, 78 
pelvis, 373 
Listerism, 70 
Liston, thigh splint, 439 

leg splint, 555 
Lockwood, fracture of humerus at birth, 

259 
Lonsdale, extension in fracture of hu- 
merus, 264 
patella, 519 
Lotions, 49 
Lower jaw, 121 



MALAR bone, 109 
Malgaigne, apparatus for fracture of 
leg, 559 
Many-tailed bandage, 54 
Maxilla, superior, 112 

inferior, 121 
Measurement of bones, 50 
of humerus, 270 
of thigh and leg, 441 
Metacarpus, 366 



904 



INDEX — FRACTURES 



Metatarsus, 567 
Metallic splints, 56 
M on ah an, fracture of astragalus, 562 
Moore, Colles's fracture, 312 
fracture of clavicle, 211 
Morbus coxa? senilis, '410 
Muhlenberg, tables of ununited fractures, 

84, 129, 202, 262, 498, 530, 543 
Mussey, fracture of coracoid process, 230 
Mutter, neck of radius, 299 



^VTECK of femur, 393 
jl\ within capsule, 394 
prognosis, 403 
G. K. Smith on, 408 
without capsule, 419 
Neck of humerus, anatomical, 234 

surgical neck, 241 
Neck of lower jaw, 123, 146 
Neck of radius, 299 
Neck of scapula, 225 
Neill, maxilla, superior, 116 

coracoid process, 230 
thigh, 449 

leg, simple fracture, 552 

compound fracture, 552 
Nelaton, radial splint, 320 
Non-union, 73 

clavicle, 202 

femur, 497 

fibula, 534 

humerus, 261 

lower jaw, 129 

patella, 503 

ribs, 188 

tibia, 530 

tibia and fibula, 543 
Norris, delayed and non-union, 73 

astragalus, 565 

gangrene from bandages, 331 

tibia, 332 
Nose, fracture of, 101 
Nott, wire splints, 56 
. thigh apparatus, 445 



ODONTOID process of axis, 175 
Olecranon process, 346 

epiphyseal separation, 354 
tenotomy, 354 
Ossa nasi, 101 



PACKARD, J. A., clavicle, 208 
inferior maxilla, tenotomy, 134 
Palmer's thigh splint, 447 
Partial fracture, 88 
Patella, 501 
Pelvis, 373 

traumatic separations, 373 
Phalanges of fingers, 370 

toes, 568 
Prognosis, general, 44 
Pubes, 373 



Q 



UADRICEPS, rupture of, 746 



RADIUS, 298 
Radius and ulna, 354 
Reduction of fractures ; general considera 

tions, 52 
Refracture of badly united legs, 561 
Repair of fracture, 38 
Resection for badly united fractures, 561 
Rheumatic arthritis, chronic, 410 
Rhinoplasty, 108 
Ribs, 186 

cartilages of, 191 
Rim of acetabulum, 385 
Rodet, neck of femur, 395 
Rogers, trephining vertebras, 162 
Roller, 54 

Rose, elbow splint, 277 
Rupture of biceps, 674 



O ACRUM, 389 

O Sacro-iliac symphysis, 390 

Salter's cradle for leg, 556 

Sargent, separation of upper maxillary 

bones, 112 
Sayre, L. A., clavicle, 212 
prognosis, 46, 437 
Scapula, 220 

body, 220 

neck, 225 

acromion process, 228 

coracoid process, 230 

epiphyses of, 228 
Scultetus, bandage, 53 
Semeiology, general, 33 
Septum narium, 108 
Setting bones, 52 
Seutin, dressing, 62 
Shaft of humerus, 259 

from muscular action, 246 

femur, 430 

radius, 302 

ulna, 333 
Shellac splints, 52 
Shoulder- joint ; differential diagnosis of 

accidents, 250 
Shrady, radius splint, 320 
Side splints, 55 

Simmons, extension apparatus, 456 
Sling for broken jaw, 143 
Smith, E. P., radial splint, 321 
Smith, Nathan R., fracture of femur, 446 
Smith, Robert, head of humerus, 235 
Smith, Stephen, fracture of lower jaw, 122 

odontoid process of axis, 177 
Smith, George K., insertion of capsule of 

hip-joint, etc., 408 
Spinal marrow, concussion, 171 
Spinous processes : vertebras, 157 

ilium, 355 
Splints, 55 



INDEX — FRACTURES 



905 



Sternum, 179 

diastasis, 379 
Styloid process of radius, 311 
Surgical neck of humerus, 241, 252, 

256 
Swing box for leg, 556 
Symphyses of pelvis, 373 

of pubes, 373 

sacro-iliac, 390 
Symphysis pubis, separation of, 373 



TARSUS, 562 
astragalus, 563 
calcaneum, 563 

Tenotomy in fractures of olecranon pro- 
cess, 354 

Thompson, fracture of lumbar vertebras, 
157 

Thyroid cartilage, 152 

Thyroid and cricoid cartilages, 152 

Tibia, 528 

Tibia and fibula, 538 

Toes, 568 

Trader's suspension apparatus, 557 

Transverse processes of spine, 158 

Treatment of fractures, general, 52 

Trephining for fracture of vertebrae, 161 

Trochanter major, 427 

Trochlea of humerus, 241 

Tubercles of humerus, 238, 251, 255 

Turner, patella splint, 520 



ULNA, resection of, 331 
Ulna. 333 
shaft, 333 

coronoid process, 337 
olecranon process, 346 
Upper epiphysis, humerus, 242 



Upper epiphysis — 

femur, 339 
Upper maxillary bones, 112 



VANDEYENTER, fracture of vertebral 
arch, 160 
Vanwagenen's suspension apparatus, 549 
Velpeau, mode of dressing fractures with 

dextrin and rollers, 62 
Vertebral arches, 159 
Vertebrae, 156 

spinous processes, 156 
transverse processes, 158 
vertebral arches, 159 
bodies, 165 

lumbar, 166 
dorsal, 168 
cervical, 169 
axis, 174 
atlas, 178 
atlas and axis, 178 



WACHERHAGEN, fractured leg, 550 
Warren on anchvlosis at elbow- 
joint, 297 
Water, warm and hot, 72 
Water-beds, 174 

Wells, internal condyle of femur, 493 
Wire-beds, 174 
Wire-splints, 56 

Wire rack for fracture of leg, 558 
Wooden splints, 57 
Wrist, 366 
Wyeth, patella splint, 520 



ZUCKERKANDL, epicondyles, 286, 291 
Zygomatic arch, 117 



58 






906 



INDEX — DISLOCATIONS 



PART II. DISLOCATIONS 



AGrNEW, D. H., rupture of axillary vein, 
659 
Anaesthetics, 590 
Ancient luxations, 584 

inferior maxilla, 593 

spine, 602 

clavicle, outer end, 625 

humerus, 653 

head of radius forwards, 680 

radius and ulna backwards, 695 

thumb, 726 

femur, 793 
Andrews, inferior maxilla, 591 
Ankle-joint, 831 
Anomalous dislocations of the hip, 785. 

See Femur. 
Anterior oblique dislocations, 788 
Astragalo-calcaneo-scaphoid dislocations, 

851 
Astragalus, 845 
Atlas, dislocations of, 610 
Axillary artery, rupture of, 657 

vein, rupture of, 659 
Ayres, dislocation of cervical vertebra, 607 



BATCHELDER, head of radius, 683 
thumb, 730 
Biceps, rupture or displacement of, 673 
Bigelow, H. J., on dislocations of hip, 743 
Blackman, ancient dislocations of hume- 
rus, 657 
femur, reduced after six months, 796 
Bloxham's dislocation tourniquet, 757 
Brainard, reduction of ancient luxation of 
elbow, 695 



CALCANEUM, dislocation of, 853 
Canton, radius and ulna forwards, 707 
Carpus, 709 

backwards, 711 
forwards, 714 
congenital, 888 
Carpal bones among themselves, 719 
Carpo-metacarpal articulations, 721 
Cartilages, of ribs from sternum, 613 
of ribs from one another, 615 
in knee-joint, 829 
Caswell, congenital dislocation of patella, 

896 
Clavicle, dislocations of, 615 
sternal end forwards, 615 
sternal end upwards, 620 
sternal end backwards, 621 
acromial end upwards, 623 
acromial end downwards, 629 
under coracoid process, 630 



Clavicle — 

both ends, 631 

congenital, 883 
Clove-hitch, 589, 727 
Compound pulleys, 590 
Compound dislocations of the long bones, 
860 

reduction in, 866 

non-reduction in, 868 

amputation in, 869 
Compound dislocations, tenotomy in, 870 

resection in, 870 
Congenital dislocations ; general observa- 
tions and history, 876 

general etiology, 877 

inferior maxilla, 879 

spine, 882 

pelvic bones, 882 

sternum, 883 

clavicle, 883 

shoulder, 884 

radius and ulna backwards, 887 

head of radius, 888 

wrist, 888 

lingers, 889 

hip, 889 

patella, 899 

knee, 897 

tarsus, 899 

toes, 899 
Cooper, Sir Astley, method of reducing 

dislocation of humerus, 649 
Coxo-femoral dislocations, 737. See Femur. 
Crosby, dislocation of thumb, 729 

ancient dislocation of elbow, 697 
Cuboid, dislocations of, 854 
Cuneiform bones, dislocation of, 855 



DAMAINVILLE, statistics of dislocations 
of femur, 758 

Darby, shoulder, 646 

Davis, Gr. P., vertical dislocation of pa- 
tella, 817 

Direct causes of dislocations, 585 

Dislocations, 583 

Division and nomenclature of dislocations, 
583 

Double dislocation of lower jaw, 593 

Dougherty, patella, 819 

Dupierris, femur reduced after six months. 
794 

Dynamometer, 756 



ELBOW-JOINT, 687 
Everted dorsal dislocation of femur, 
746 



INDEX — DISLOCATIONS. 



90T 



Exciting causes, general, 585 
Extension by a twisted rope, 590, 755 



FEMUR, dislocation of, 737 
dislocation on dorsum ilii, 740 

reduction by manipulation, 747 
reduction by extension, 753 
dislocation into great iscliiatic notch, 

766 
below the tendon, 769 
dislocation into the foramen thyroid- 

eum, 774 
dislocation upon the pubes, 780 
anomalous dislocations of the femur, 
785 
downwards and backwards upon 

the body of the ischium, 789 
downwards and backwards into 

lesser iscliiatic notch, 790 
behind the tuber ischii, 789 
dislocation directly up, 785 
directly down, 791 
forwards into perineum, 791 
ancient dislocations, 793 
partial dislocations, 800 
with fracture, 801 
in children, 584, 738 
congenital, 889 
voluntary, 804 
Fenner, dislocation of femur on dorsum 

ilii, 741 
Fibula, upper end forwards, 842 
backwards, 843 
lower end, 844 
"Fifth" dislocation of femur, 790 
Fingers, dislocations of first phalanx, 
764 
second and third, 735 
congenital, 889 
voluntary, 810 
Foot, dislocation outwards, 831. See Tibia. 
Fountain, dislocation of femur upon 
pubes, 783 



GAZZAM, rotation of patella on its inner 
margin, 816 
General division, 583 

direct or exciting causes, 585 
predisposing causes, 584 
prognosis, 588 
pathology, 586 
treatment, 588 
symptoms, 585 
Gerster, dislocation of long head of biceps, 

677 
Gibson, ancient dislocation of humerus, 

658 
Gilbert, A. W., dislocation of lower jaw, 

592 
Grant, astragalus, 850 
Graves, dislocation of dorsal vertebne, 601 
Gunn, dislocation of thigh on dorsum ilii, 
742 



HART, dislocation of astragalus, 848 
Hartshorne, reduction of humerus by 
manipulation (note), 662 
Head upon the atlas, 612 
Haynes, S., double dislocation of clavicle, 

632 
Hickerman, cervical vertebrae, 606 
Hip, congenital dislocations of, 889 
Hodge, statistics of dislocations of the fe- 
mur, 738, 760 
Horner, partial dislocation of fourth cer- 
vical vertebras, 604 
Howe, reduction of dislocation of the hip 

by manipulation, 750 
Humerus, dislocations of, 633 
double, 663 
downwards, 633 
forwards, 662 
fracture in reduction, 660 
backwards, 670 
partial, 672 
ancient, 653 

rupture of axillary artery, 657 
rupture of axillary vein, 659 
rupture of axillary artery and vein, 

659 
cerebral congestion, 659 
injury to axillary nerves, 659 
avulsion of arm, 659 
inflammation, 659 
congenital, 884 
Humero-scapular dislocation, 633. See 

Humerus. 
Hutchison, dislocation of femur, 768 



ILIO FEMORAL ligament, 743 
Ilio-pubic dislocation of femur, 714 
Indian "puzzle," 653, 732 
Inferior maxilla, 591 

double dislocation, 591 
single dislocation, 595 
congenital dislocation, 879 
Ingalls, reduction of dislocation of hip by 

manipulation, 752 
Internal derangement of knee-joint, 829 
Ischio-pubic dislocation of femur, 774 
Iscliiatic dislocation of femur, 766 



ARVIS'S adjuster, 590, 655, 756 
Jaw, lower, 591 



KIRKBRIDE, dislocation of the femur 
upon posterior part of the body of the 
ischium, 790 
Knee, slipping of semilunar cartilages, 

829. See Tibia. 
Krackowizer, dislocation of head of radius 
in delivery, 679 



A MOTHE, method of reducing disloca- 
i tion of humerus, 648 



908 



INDEX — DISLOCATIONS. 



Lehman, spontaneous dislocation of shoul- 
der, 634 
Lente, fifth cervical vertebra, with frac- 
ture, 604 
fifth cervical vertebra, without frac- 
ture, 604 
femur directly upwards, 787 
Levis, reduction of dislocation of thumb, 

731 
Ligamentum patellae, rupture of, 819 
Lister, rupture of axillary artery, 658 
Long bones, compound dislocation in, 860 
Long head of biceps, displacement of, 674 
Lower jaw, 591 

double dislocation, 591 
single dislocation, 595 
simulating luxation of, 596 
Lumbar vertebrae, 599 
Lun are, 720 



MAGNUM, 719 
and cuneiform, 720 
Markoe, on reduction of dislocation of fe- 
mur, 752 
head of radius backwards, 683 
femur with fracture reduced, 803 
Maxilla, inferior, congenital, 879 
Maxson, dislocation of cervical vertebrae, 

606 
Mercer, on partial dislocations of humerus, 

676 
Metacarpus, 721 

Metacarpophalangeal articulation, 725 
Metatarsus, 857 
Middle carpal dislocation, 721 

tarsal dislocation, 853 
Moore, on reduction of dislocation of fe- 
mur, 742 
ulna, 716 
Mussey, dislocation of the thumb, 729 
ancient dislocation of elbow, 697 



"YT ORRIS, ancient dislocations of the hu- 
ll merus, 661, 665 

dislocation of humerus mistaken for 

a contusion, 665 
compound dislocation of thumb, 732 
North, N. C, double dislocation of clavi- 
cle, 631 







CCIPITO-ATLOIDEAN dislocations, 612 



PACKARD, John H., dislocation of great 
toe, 785 
Pardee, E. L., double dislocation of hume- 
rus, 663 
Parker, head of humerus in subscapular 
fossa, 664 
backwards, 670 
head of radius backwards, 683 



Parker — 

head of radius outwards, 686 

femur into perineum, 792 
Patella, outwards, 812 

inwards, 815 

on its axis, 815 

upwards ; 819 

downwards, 820 

spontaneous, 812 

congenital, 896 
Pathology, general, 586 
Pelvis, congenital, 882 
Peroneo-tibial, 844 
Pettit, A., dislocation of tibia, 825 
Phalanges, thumb and fingers, 725 

toes, 859 
Pisiform, 702 
Pope, dislocation of femur into perineum, 

792 
Predisposing causes, general, 584 
Prognosis, general, 588 
Pseudo-luxations of inferior maxilla, 596 
Pulleys, 590 

Purple, dislocation of cervical vertebrae, 
604 



Q 



UADRICEPS, rupture of, 820 



RADIUS, head dislocated forwards, 678 
backwards, 683 
outwards, 685 
congenital, 888 
Radius and ulna, dislocation backwards, 
687 
congenital, 887 
outwards, 697 
inwards, 704 
forwards, 706 
Radius forwards and ulna backwards, 

708 
Radio-carpal articulation, 709. See Carpus. 
Radio-ulnar articulation, inferior, 716 
Rupture of quadriceps femoris, 820 
Rupture of biceps, 674 
Reid, reduction of dislocation of femur by 

manipulation, 752 
Ribs from vertebrae, 612 
from sternum, 616 
one cartilage, upon another, 615 
Rochester, sternal end of clavicle upwards, 

620 
Rudiger, dislocation of dorsal vertebrae, 
601 



SACRO-SCIATIC dislocation of femur, 
766 
Sanson, third cervical vertebra, 604 
Scaphoid, dislocation of, 854 
Scapula, 809 

Schuk, dislocation of cervical vertebra, 
605 



INDEX — DISLOCATIONS. 



909 



Shoulder, dislocations of, 633. See Hu- 
merus. 
Single dislocation of lower jaw, 595 
" Sixth" dislocation of femur, 785 
Skey, method of reducing dislocation of 

humerus, 650 
Smith, Nathan, on reduction of disloca- 
tion of the humerus, 647 
reduction of femur by manipulation, 
749 
Smith, H. H., on reduction of humerus, 

652 
Spencer, dislocation of cervical vertebra, 

605 
Spine, 598. See Vertebrae. 
Spontaneous dislocations. See Voluntary 

Dislocations, p. 804 
Squier, T. H., dislocation of radius and 

ulna inwards, 705 
Sternum, 621 
Sternum, congenital, 883 
Sternberg, vertical dislocation of patella, 

817 
Subcoracoid dislocation of humerus, 662 
Subclavicular dislocation of humerus, 

662 
Subcotyloid dislocation of femur, 791 
Subluxation of the jaw, 596 
Subglenoid dislocation of the humerus, 

633 
Subpubic dislocation of femur, 774 
Subspinous dislocation of humerus, 670 
Swan, dislocation of dorsal vertebra, 602 
Symptomatology, general, 585 



TARSUS, 845 
astragalus, 845 

astragalo-calcaneo-scaphoid, 851 
calcaneum, 853 
middle tarsal dislocation, 853 
os cuboides, 854 
os scaphoides, 854 
cuneiform bones, 856 
congenital, 899 
voluntary, 812 
Tendons, dislocation of, 674 
Thigh, 737. See Femur. 
Thumb, first phalanx, 725 
backwards, 725 
forwards, 732 
second phalanx, 735 
Tibia, dislocation of upper end, 820 
backwards, 821 
forwards, 823 
outwards, 825 
inwards, 827 

backwards and outwards, 827 
congenital, 897 
lower end, inwards, 831 
outwards, 836 
forwards, 837 



Tibia, lower end — 

backwards, 841 
Tibio-tarsal luxations, 831 
Toes, 859 

congenital, 899 
Treatment, general, 588 
Tripod for vertical extension of femur, 766 
Trowbridge, head of humerus backwards, 

670 
Twisted rope extension, 590 



ULNA, upper end backwards, 686 
lower end backwards, 716 
forwards, 717 
Unilateral luxation of lower jaw, 595 



VAN BUREN, W. H., dislocation of hu- 
merus backwards, 670 

reduction of femur by manipulation, 
761, 777 
Varick, T. R., radius and ulna outwards, 

698 
Vertebrae, 598 

lumbar, 599 

dorsal, 600 

six lower cervical, 603 

atlas upon axis, 610 

head upon atlas, 612 

congenital dislocations, 882 
Voluntary and spontaneous dislocations, 
804 

inferior maxilla, 596, 808 

scapula, 809 

humerus, 809 

wrist-joint, 809 

phalanges of fingers, 810 

hip-joint, 810 

knee-joint, 811 

ankle-joint, 812 

tarsal-joints, 812 

patella, 812 



WARM water, 72 
Warren, C. H., the contortionist, vol- 
untary dislocation, 807 
Waterman, T., reduction of elbow, 687 
Watson, dislocation of patella outwards, 

813 
Wells, dislocation of tibia, 828 
Windlass for extension, 590, 755 
Wood, dislocation of cervical vertebrae. 
607 
humerus, with fracture, 664 
Wrist, 709. See Carpus. 



ligament, 743 
Youmans, J., congenital dislocation 
of knee, 897 



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the dissemination of sound medical literature. They trust, especially, that the sub- 
scribers to the "American Medical Journal," will call the attention of their 
acquaintances to the advantages thus offered, and that they will be sustained in the 
endeavor to permanently establish medical periodical literature on a footing of cheap- 
ness never heretofore attempted. 

PKEMIUM FOE, OBTAINING NEW SUBSCRIBERS TO THE "JOURNAL." 

Any gentleman who will remit the amount for two subscriptions for 1880, one of 
which at least must be for a new subscriber, will receive as a premium, free by mail, 
a copy of any one of the following recent works : — 

"Barnes's Manual of Midwifery" (see p. 24), 

"Tilbury Fox's Epitome of Diseases of the Skin," new edition (see 

p. 18), 
"Fothergill's Antagonism of Medicines" (see p. 16), 
"Holden's Landmarks, Medical and Surgical" (see p. 6), 
"Browne on the Use of the Ophthalmoscope" (see p. 29), 
"Flint's Essays on Conservative Medicine" (see p. 15), 
" Sturges's Clinical Medicine" (see p. 14), 
" Swayne's Obstetric Aphorisms," new edition (see p. 21), 
"Tanner's Clinical Manual" (see p. 5), 
"West on Nervous Disorders of Children" (see p. 20). 

*£* Gentlemen desiring to avail themselves of the advantages thus offered will d©> 
well to forward their subscriptions at an early day, in order to insure the receipt of" 
complete sets for the year 1880. 

Ig|p° The safest mode of remittance is by bank check or postal money order, drawn 
to the order of the undersigned. Where these are not accessible, remittances for the 
"Journal" may be made at the risk of the publishers, by forwarding in registered 
letters. Address, 

Henry C. Lea's Son & Co., Nos. 706 and 708 Sansom St., Phila., Pa. 



Henry C. Lea's Son & Co.'s Publications — {Dictionaries). 



jyUNGLISON (ROBLEY), M.D., 

Late Professor of Institutes of Medieinein Jefferson Medical College, Philadelphia. 

MEDICAL LEXICON; A Dictionary op Medical Science: Con- 
taining a concise explanation of the various Subjects and Terms of Anatomy, Physiology, 
Pathology, Hygiene, Therapeutics. Pharmacology, Pharmacy, Surgery, Obstetrics, Medical 
Jurisprudence, and Dentistry. Notices of Climate and of Mineral Waters j Formulae for 
Officinal, Empirical, and Dietetic Preparations ; with the Accentuation and Etymology of 
the Terms, and the French and other Synonymes ; so as to constitute a French as well as 
English Medical Lexicon. A New Edition. Thoroughly Revised, and very greatly Mod- 
ified and Augmented. By Richard J. Dunglison, M.D. In one very large and hand- 
someroyaloctavo volume of over 1100 pages. Cloth, $6 50 j leather, raised bands, $7 50; 
half Russia, $8. (Just Issued.) 
The object of the author from the outset has not been to make the work a mere lexicon or 
dictionary of terms, but to afford, undereach, a condensedview of itsvariousmedical relations, 
and thus to render the work an epitome of the existing condition of medical science. Starting 
with this view, the immense demand which has existed for the work has enabled him, in repeated 
revisions, to augmentits completeness and usefulness, until at lengthit has attained the position 
of a recognized and standard authority wherever the language is spoken. 

Special pains have been taken in the preparation of the present edition to maintain this en- 
viable reputation. During the ten years which have elapsed since the last revision, the additions 
to the nomenclature of the medical sciences have been greater than perhaps iD any similar period 
of the past, and up to the time of his death the author labored assiduously to incorporate every- 
thing requiring the attention of the student or practitioner. Since then, the editor has been 
equally industrious, so that the additions to the vocabulary are more numerous than in any pre- 
vious revision. Especial attention has been bestowed on the accentuation, which will be found 
marked on every word. The typographical arrangement has been much improved, rendering 
reference much more easy, and evsry care has been taken with the mechanical execution. The 
work has been printed on new type, small but exceedingly clear, with an enlarged page, so that 
the additions have been incorporated with an increase of but little over a hundred pages, and 
the volume now contains the matter of at least four ordinary octavos. 

may safely confirm the hope ventured by the editor 
" that the work, which possesses for him a filial as well 
as an individual interest, will be fouDd worthy a con- 
tinuance of the position so Ions: accorded to it as a 
standard authority." — Cincinnati Clinic, Jan. 10, 1874. 
It has the rare merit that it certainly has no rival 
in the English language for accuracyand extent of 
references. — London Medical Gazette, 



A book well known to our readers, and of which 
every American ought to be proud. When the learned 
author of the work passed away, probably all of us 
feared lest the book should not maintain its place 
in the advancing science whose terms it defines. For- 
tunately, Dr. Richard J. Dunglison, having assisted his 
father in the revision of several editions of the work, 
and having been, therefore, trained in the methods and 
imbued with the spirit of the book, has been able to 
edit it, not in the patchwork manner so dear to the 
heart of book editors, so repulsive to the taste of intel- 
ligent book readers, but to edit it as a work of the kind 
8houldbe edited — to carry it on steadily, without jar 
or interruption, aloug the grooves of thought it has 
travelled during its lifetime. To show the magnitude 
of the task which Dr. Dunglison has assumed and car- 
ried through, it is only necessary to state that more 
than six thousand new subjects have been added in the 
present edition.— Phila. Med. Times, Jan. 3, 1874. 

About the first book purchased by the medical stu- 
dent is the Medical Dictionary. The lexicon explana- 
tory of technical terms is simply a sine qua non. In a 
science so extensive, and with such collaterals as medi 
cine, it is as much a necessity also to the practising 
physician. .To meet the wants of students and most 
physicians, the dictionary must be condensed while 
comprehensive, and practical while perspicacious, ft 
was because Duoglison's met these indications that it 
became at once the dictionary of general use wherever 
medicine was studied in the English language. In no 
former revision have the alterations and additions been 
so great. M-jretban six thousand new subjects and terms 
have been .added . The chief terms have been set in black 
letter, while the derivatives follow in small caps; an 
arrangement which greatly facilitates reference. We 



As a standard work of reference, as one of the best, 
if not the very best, medical dictionary in the Eng- 
lish language, Dunglison's work has been well known 
for about forty years, and needs no words of praise 
on our part to recommend it to the members of the 
medical, and, likewise, of the pharmaceutical pro- 
fession. The latter especially are in need of such a 
work, which gives ready and reliable information 
on thousands of subjects and terms which they are 
liable to encounter in pursuing their daily avoca- 
tions, but with which they cannot be expected to be 
familiar. The work before us fully supplies this 
want. — Am. Journ. of Pharm., Feb. 187-1. 

A valuable dictionary of the terms employed in 
medicine and the allied sciences, and of the rela- 
tions of the subjects treated under each head. It re- 
flects great credit on its able American author, and 
well deserves the authority and popularity it has 
obtained.— British Med. Journ., Oct. 31, 1874. 

Few works of this class exhibit a grander monu- 
ment of patient research and of scientific lore. The 
extent of the sale of this lexicon is sufficient to tes- 
tify to its use'ulness, and to the great service con- 
ferred by Dr. Rabley Dunglison on the profession, 
and indeed on others, by its issue. — London Lancet, 
May 13. 1875. 



ffOBLYN {RICHARD D.), M.D. 

A DICTIONARY OF THE TERMS USED IN MEDICINE AND 

THE COLLATERAL SCIENCES. Revised, with numerous additions, by Jsaac Hays, 
M. D., Editor of the " American Journal of the Medical Sciences." In one large royal 
l2mo. volume of over 500 double-columned pages ; cloth, $1 50 ; leather, $2 00. 

,It is the best boojk of definitions we have, and ought always to be upon the student's table.— Southern 
Med. and Sur_g. Journal. 



R 



ODWELL (£. F.), F.R.A.S., frc. 

A DICTIONARY OF SCIENCE: Comprising Astronomy, Chem- 
istry, Dynamics, Electricity, Heat, Hydrodynamics, Hydrostatics, Light, Magnetism, 
Mechanics, Meteorology, Pneumatics, Sound, and Statics. Preceded by an Essay on the 
History of the Physical Sciences. In one handsome octavo volume of 694 pages, and 
many illustrations.:, cloth, $5. 



Henry C. Lea's Son & Co.'s Publications — (Manuals). 5 

A CENTURY OF AMERICAN MEDICINE. 1776-1876. By Doctors B. H. 
«^*- Clarke, H. J. Bigelow, S. D. Gross, T. Gr. Thomas, and J. S. Billings. Inone very hand- 
some 12mo. volume of about 350 pages : cloth, $2 25. (Lately Issued.) 

This work appeared in the pages of the American Journal of the Medical Sciencesduring the 
year 1876. As a detailed account of the development of medical science in America, by gentle- 
men of the highest authority in their respective departments, the profession will no doubt wel 
come it in a form adapted for preservation and reference. 



lyEILL (JOHN), M.D., and VMITH {FRANCIS G.), M.D., 

-*~ " Prof, of the Institutes of Medicine inthe Univ. of Penna. 

AN ANALYTICAL COMPENDIUM OF THE VARIOUS 

BRANCHES OF MEDICAL SCIENCE; for the Use and Examination of Students. A 
new edition, revised and improved. In one very large and handsomely printed royal 12mo. 
volume, of about one thousand pages, with 374 wood-cuts, cloth, $4 ; strongly bound in 
leather, with raised bands, $4 75. 



H 



ARTSHORNE {HENRY), M.D., 

Professor of Hygiene in the University of Pennsylvania. 

A CONSPECTUS OF THE MEDICAL SCIENCES; containing 

Handbooks on Anatomy, Physiology, Chemistry, Materia Medica, Practical Medicine, 
Surgery, and Obstetrics. Second Edition, thorougbly revised and improved. In one large 
royal 12mo. volume of more than 1000 closely printed pages, with 477 illustrations on 
wood. Cloth, $4 25 ; leather, $5 00. (Lately Issued.) 
We can say with the strictest truth that it is the I worthy. If students must have a conspectus, they 
best work of the kind with which w<l artacquainted. I will be wise to procure that of Dr. Hartshorne.— 
It embodies in a condensed form ail recent contribu- i Detroit Rev. of Med and Pkarrn., Aug 1874 
tions to practical medicine ana is therefore useful I The work before however has ma redeem- 
to every busy practiUoner throughout our country I ■ feature , QOt posses ' sed by 0[hers . aDd J the £ 
besides being admirably adapted to the ube of stu- , we have8een . Dr. Hartshorne exhibits much skill in 
dents of medicine. The book is faithfully and ably , condensation It is well adapted to the physician in 
executed.— Charleston Med. Journ., April, 187o. active practice) who can give but limited time to the 

The work is intended as an aid to the medical | familiarizing of himself with the important changes 
student, and as such appears to admirably fulfil its j which have been made since he attended lectures. 



object by itsexcellent arrangement, the full comp 
lation of facts, the perspicuity aud terseness of lan- 
guage, and the clear and instructive illustrations 
in some parts of the work. — American Journ. of 



The manual of physiology has also been improved 
and gives the most comprehensive view of the latest 
advances in the science possible in the space devoted 
to the subject. The mechanical exscution of the 



Pharmacy, Philadelphia, July, 187-4. j book leaves nothing to be wished for.— Peninsular 

The volume will be found useful, not only to stu- Journal of Medicine, Sept. 1874. 
dents, but to many otherswhomay desire torefresh . After carefully looking through this conspectus, 
their memories with the smallest possible expendi- we are constrained to say that it is the most com- 
ture of time. — N. Y. Med. Journal, Sept. 1874. plete work, especially in its illustrations, of its kind 

The student will find this the most convenient and that we have seen.— Cincinnati Lancet, Sept. 1874. 
useful book of the kind on which he can lay his The favor with wM(jh lhe firgt editi<m of thifJ 
hand.— Pacific Med. and Surg. Journ., Aug. 1S74. [ Compendium was received, was an evidence of its 
This is the best book of its kind that we have ever i various excellences. The present edition bears evi- 
examined. It is an honest, accurate, and concise deuce of a careful and thorough revision. Dr. Harts- 
compend of medical sciences, as fairly as possible home possesses a happy faculty of seizing upon the 
representing their present condition. The changes j salient points of each subject, and of presenting them 
and the additions have been so judicious and tho- j in a concise and yet perspicuous manner. — Leavtn- 
rough as to render it, so far as it goes, entirely trust- j worth Mad. Herald, Oct. 1874 



T UDLOW (J.L.), M.D. 
A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, 

Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and 
Therapeutics. To which is added a Medical Formulary. Third edition, thoroughly revised 
and greatly extended and enlarged. With 370 illustrations. In one handsome royal 
l2mo. volume of 816 large pages, cloth, $3 25 ; leatber, $3 75. 
The arrangement of this volume in the form of question and answer renders it especially suit- 
bie for the office examination of students, and for those preparing for graduation. 



fTANNER {THOMAS HAWKES), M.D., Sfc. 

A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAG- 
NOSIS. Third American from the Second London Edition. Revised and Enlarged by 
Tilbury Fox, M. D., Physician to the Skin Department in University College Hospital, 
<fcc. In one neat volume small 12mo., of about 375 pages, cloth, $150. 
*^* On page 3, it will be seen that this work is offered as a premium for procuring new 
subscribers to the "American Journal op the Medical Sciences.'' 



6 



Henry C. Lea's Son & Co.'s Publications— (Jrcafowy). 



QRAY {HENRY), F.R.S., 

Lecturer on Anatomy at St. George's Hospital, London. 

ANATOMY, DESCRIPTIVE AND SURGICAL. The Drawings by 

H. V. Carter, M.D., and Dr. Westmacott. The Dissectionsjointly by the Author and 
Dr. Carter. With an Introduction on General Anatomy and Development by T. 
Holmes, M.A., Surgeon to St George's Hospital. A new American, from the eighth 
enlarges and improved London edition. To which is ndded " Landmarks, Medical and 
Surgical," by Luther Holden. F.K.C.S., author of "Human Osteology," '• A Manual 
of Dissections," etc. In one magnificent imperial octavo volume of 983 pagres. with 
522 large and elaborate engravings on wood. Cloth, $6 ; leather, raised bands, $7 ; 
half Russia, $7 50. (Just Ready.) 
The author has endeavored in this work to cover a more extendedrange of subjects than is cut • 
tomary in the ordinary text-books, by giving not only the details necessary for the student, but 
also the application of those details in the practice of medicine and surgery, thus rendering it both 
a guide for the learner, and an admirable work of reference for the active practitioner The en- 
gravings form a special feature in the work, many of them being the size of nature, nearly all 
original, and having the names of the various parts printed on the body of the cut, in place of 
figures of reference, with descriptions at the foot. They thus form a complete and splendid series, 
which will greatly assist the studentin obtaining a clear idea of Anatomy, and will also serve to 
refresh the memory of those who may find in the exigencies of practice the necessity of recalling 
the details of the dissecting room ; while combining, as it does, a complete Atlas of Anatomy, witt 
a thorough treatise on systematic, descriptive, and applied Anatomy, the work will be found of 
essential use to all physicians who receive students in their offices, relieving both preceptor and 
pupil of much labor in laying the groundwork of a thorough medical education. 

Since the appearance of the last American Edition, the work has received three revisions at the 
hands of its accomplished editor, Mr. Holmes, who has sedulously introduced whatever has seemed 
requisite to maintain its reputation as acomplete and authoritative standard text-book and work 
of reference. Still further to increase its usefulness, there has been appended to it the recent 
work by the distinguished anatomist, Mr. Luther Holden — "Landmarks, Medical and burgical" 
which gives in a clear, condensed, and systematic way, all the information by which the prac- 
titioner can determine from the external surface of the body the position of internal parts. Thus 
complete, the work, it is believed, will furnish all the assistance that can be rendered by type and 
illustration in anatomical study. No pains have been spared in the typographical execution of 
the volume, which will be found in all respects superior to former issues. Notwithstanding the 
increase of size, amounting to over 100 pages and 57 illustrations, it will be kept, as heretofore, 
at a price rendering it one of the cheapest works ever offered to the American profession. 



The recent work of Mr Holden, which was no- 
ticed by us on p. 53 of this volume, has been added 
as an appendix, so that, altogether, this is the moi t 
practical and complete anatomical treatise available 
to American students and physicians. The former 
finds in it the necessary guide in making dissec- 
tions; a very comprehensive chapter on minute 
anatomy; and about all that can be taught him on 
general and special anatomy; while the latter, in 
its treatment of each region from a surgical point of 
view and in the valuable edition of Mr Holden, 
will find all that will be essential to him in his 
practice —New Remedies, Aug 1S78. 

This work is as near perfection as one could pos- 
sibly or reasonably expect any book intended as a 
text-book or a genera) reference book on anatomy 
to be. The American publisher deserves the thunks 
of th<* profession for appending the recent work of 
Mr. Holden, "Landmarks, Medical and S"-i gical," 
which has already been commended as a separate 
book. The latter work— treating of topograph. cal 
anatomy— has become an essential to the library of 
every intelligent practitioner. We know of no 
book that can take its place, written as it is by a 
most distinguished anatomist. It would be simply 
a waste of words to say anything further in praise 
of Gray's Anatomy, the text-book in almost every 
medical college in this country, and the daily refer 
ence book of every practitioner who has occasion 



to consult his books on anatomy. The work is 
simply indispensable, especially this present Amer- 
ican edition.— Fa. Med. Monthly, Sept. 187P. 

The addition of the recent work of Mr. Holden, 
as an appendix, renders this the most practical and 
complete treatise available to American students, 
who find in it a comprehensive chapter on minute 
anatomy, about all that can be taught on general 
and special anatomy, while its treatment of each 
region, from a surgical point of vie v, in the valu- 
able section by Mr. Holden. is all that will be essen- 
tial to them in practice.— Ohio Mtdical Recorder, 
Aug 187S. 

It is difficult to speak in moderate terms of this 
new edition of "Gray." It seems to be as nearly 
perfect as it is possible to make a book devoted to 
any branch of medical science. The labors of the 
eminent men who have successively revised the 
eight editions through which it has passed, would 
seem to leave nothing for future editors to do. The 
addition of Holden's " Landmarks" will make it as 
indispensable to the practitioner of medicine aud 
surgery as it has been heretofore to the student. As 
regards completeness, ease of reference, utility, 
beauty, and cheapness, it has no rival. No stu- 
dent should enter a medical school wiihoutit; no 
physician can afford to have it absent from his 
library— St. Louis Clin. Record, Sept 1S7S. 



R 



H 



Also for sale separate — 
VLD EN {LUTHER), F.R.C.S., 

Surgeon to St. Bartholomew's and the Foundling Hospitals. 

LANDMARKS, MEDICAL AND SURGICAL. From the 2d London 

Ed. In one handsome volume, royal l2mo., of 128 pages : cloth, 88 cents. (Now Ready.) 

EATH {CHRISTOPHER), F.R.G.S., 

Teacher of Operative Surgery in University College, London. 

PRACTICAL ANATOMY: A Manual of Dissections. From the 

Second revised and improved London edition. Edited, with additions, by W. W. Keen, 
M. D., Lecturer on Pathological Anatomy in the Jefferson Medical College, Philadelphia. 
In one handsome royal 12mo. volume of 578 pages, with 247 illustrations. Cloth, $3 50 ; 
leather, $4 00. 



Henry C. Lea's Son & Co.'s Publications — (Anatomy). 7 

A LLEN {HARRISON), M.D. 

•£*- Professor of Physiology in the Univ. of Pa. 

A SYSTEM OF HUMAN ANATOMY: INCLUDING ITS MEDICAL 

and Surgical Relations. For the Use of Practitioners and Studentsof Medicine. With an 
Introductory Chapter on Histology By E. 0. Shakespeare, M D , Ophthalmologistto the 
Pbila. Hosp. In one large and handsome quarto volume, with several hundred original 
illustrations on lithographic plates, and numerous wood-cuts in the text. (In Press.) 
In this elaborate work, which has been in active preparation for several years, the author has 
sought to give, not only the details of descriptive anatomy in a clear and condensed form, but also 
the practical applications of the science to medicine and surgery. The work thus has claims upon 
the attention of the general practitioner, as well as of the student, enabling him not only to re- 
fresh his recollections of the dissecting room, but also to recognize the significance of all varia- 
tions from normal conditions. The marked utility of the object thus sought by the author is 
self-evident, and his long experience and assiduous devotion to its thorough development area 
sufficient guarantee of the manner in which his aims have been carried out. No pains have been 
spared with the illustrations. Those of normal anatomy are from original dissecti ms, drawn on 
stone by Mr. Hermann Faber, with the name of every part clearly engraved upon the figure, 
after the manner of " Holden" and " Gray, " and in every typographical detail it will be the 
effort of the publisher to render the volume worthy of the very distinguished position which is 
anticipated for it. 

T^LLIS {GEORGE V1NER)~ 

J-J Emeritus Prof tssor of Anatomy in University College, London. 

DEMONSTRATIONS OF ANATOMY; Being a Guide to the Know- 

ledge of the Human Body by Dissection. By George Viner Ellis, Emeritus Professor 
of Anatomy in University College, London. From the Eighth and Revised London 
Edition. In one very handsome octavo volume of over 700 pages, with 256 illustrations. 
Cloth, $4.25 ; leather, $5.25. (Jvst Ready.) 
This work has long been known in England as the leading authority on practical anatomy, 
and the favorite guide in the dissecting-room, as is attested by the numerous editions through 
which it has passed. In the last revision, which has just appeared in London, the accomplished 
author has sought to bring it on a level with the most recent advances of science by making the 
necessary changes in his account of the microscopic structure of the different organs, as devel- 
oped by the latest researches in textural anatomy. 

Ellis's Demonstrations is the favorite text-book 
of the English student of anatomy. In passing 
through eight editions it has been &o revised and 



adapted to the needs of the student baf it would 
seem that it had almost reached perfection in this 



its leadership over the English manuals upon dis- 
secting.— Phiia. Med. Times, May 24, 1879. 



As a dissector, or a work to have in band and 
studied while one is engaged in dissecting, we re- 



special line. The descriptions are clear, and the j § ard ic as the v ^ r 7 De6t w *>rk extant, which is cer- 
methods of pursuing anatomical investigations are tainly saying a very great deal. As a text-book to 
given with such detail that the book is honestly I be ^studied in the jiissecting-room, it_ is superior to 
entitled to its name. — St. Louis Clinical Record, ~ 
June, 1879. 

The success of this old manual seems to be as well 
deserved in the present as in the past volumes. 
The book deems destined to maintain yet for years 



any of the works upon anatomy.— Cincinnati Med. 
News, May 24, 1879. 

We most unreservedly recommend it to every 
practitioner of medicine who can possibly get it. — 
Va. Med. Monthly, June, 1879. 



w 



ILSON (ERASMUS), F.R.S. 

A SYSTEM OF HUMAN ANATOMY, General and Special. Edited 

by W. H.Gobrecht, M.D, Professor of General and Surgical Anatomy in the Medical Col- 
lege of Ohio. Illustrated with three hundred and ninety-seven engravings on wood. In 
one large and handsome octavo volume, of over 600 large pages ; cloth, $4 ; leather, $5. 

gMITR {HENRY R.), M.D., and JJORNER ( WILLIAM E.),M.D., 

Prof, of Surgery in the Univ. ofPenna., &e. Late Prof, of Anatomy in the Univ. ofPenna. 

AN ANATOMICAL ATLAS ; illustrative of the Structure of the 

Human Body. In one volume, large imperial octavo, cloth, with about six hundred and 
fifty beautiful figures. $4 50. 

CHAFER {ED WARD ALBERT), M.D. , 

Assistant Professor of Physiology in University College, London. 

A COURSE OF PRACTICAL HISTOLOGY: Being an Introduction to 

the Use of the Microscope. In one handsome royal 12mo. volume of 304 pages, with 
numerous illustrations: cloth, $2 00. (Just Issued.) 

HORNER'S SPECIAL ANATOMY AND HISTOL- , for their Pass Examination. With engravings on 

OGT. Eighth edition, extensively revised and wood In one handsome royal 12mo. volume 

modified. In 2 vols. Svo., of over 1000 pages, Cloth, $225. 

with 320 wood-cuts : cloth, $6 00 CLELAND'S DIRECTORY FOR THE DISSECTION 

SHARPEY AND QUAIN'S HUMAN ANATOMY. OF THE HUMAN BODY. In one small volume, 

Revised, by Joseph Leidy, M.D.,Prof of Anat. royal 12mo. of 1S2 pages: aloth $1 25 

5°?^ Sfui/m'l!!- T °n?\°J 2*°™ i HARTSHORNE'S HANDBOOK OF ANATOMY AND 
U00 pages, with 51Hllustrations Cloth, $6 00. i PHYSIOLOGY. Second edition, revised. In one 
BELLAMYS STUDENT'S GUIDE TO SURGICAL 1 royal 12mo. vol., with 220 woodcuts: cloth 
ANATOMY : A Text-book for Students prepa:iig { $1 75. 



S 



8 Henry C. Lea's Son & Co.'s Publications — {Physiology). 

SlARPENTER ( WILLIAM B.), M.D., F.R.S., F.G.S., F.L.S., 

^ Registrar to University of London, etc. 

PRINCIPLES OF HUMAN PHYSIOLOGY; Edited by HenryPower, 

M.B. Lond., F.R.C.S., Examiner in Natural Sciences, University of Oxford. Anew 
American from the Eighth Revised and Enlarged English Edition, with Notes and Addi- 
tions, hy Francis G. Smith, M.D., Professor of the Institutes of Medicine in the Univer- 
sity of Pennsylvania, etc. In one very large and handsome octavo volume, of 1083 pages, 
with two plates and 37'S engravings on wood; cloth, $5 50 ; leather, $6 50 ; half Russia, 
$7. {Just Issued.) 



"We have been agreeably surprised to find the vol- 
ume so complete in regard to the structure and func- 
tions of the nervous system in all its relations, a 
subject that, in many respects, is one of the most diffi- 
cult of all, in the whole range of physiology, upon 
which to produce a full and satisfactory treatise of 
the class to which the one before us beloogs. The 
additions by the American editor give to the work as 
it is a considerable value beyond that of th« last 
English edition, lu conclusion, we can give our cor- 
dial recommendation to the work as it now appears 
The editors have, with their additions to the only 
work on physiology in our language that, in the full- 
est sen-e of the word, is the production of a philoso- 
pher as well as a physiologist, brought it up as fully 
as could be expected, if not desired, to the standard 
of our knowledge of its subject at the present day. 
It will deservedly maintain the place it has always 
had in the favor of he medical profession. — Journ. 
of Nervous and Mental Disease, April, 1877. 

Such enormous advances have recently been made in 
our physiological knowledge, that what was perfectly ( 



new a year or two ago. looks now as if it had been a 
received and established fact for years. In this ency- 
clopaedic way it is unrivalled. Here, as it seems to 
us. is the great vaiue of the book: one is safe in sending 
a student to it for information on almost any given 
subject, perfectly certain of the fulness of information 
it will convey, and well satisfied of the accuracy with 
which it will there be found stated. — London Med. 
Times avd Gazette, Feb. 17, 1877. 

The merits of "Carpenter's Physiology" are so widely 
known and appreciated that we need only allude briefly 
to the fact that in the latest edition will be found a com- 
prehensive embodiment of the results of recent physio- 
logical investigation. Care has been taken to preserve 
the practical character of the original work. In fact 
the entire work has been brought up to date, and bears 
evidence of the amount of labor that has been bestowed 
upon it by its distinguished editor, Mr. Henry Power. 
The American editor has made the latest additions, in 
order fully to cover the time that has elapsed since the 
last English edition.— -N. Y. Med. Journal, J an. 1877 . 



IjTOSTER [MICHAEL), M.D., F.R.S., 

J- Prof, of Physiology in Cambridge Univ., England. 

TEXT-BOOK OF PHYSIOLOGY. A new American* from the last 

English edition. Edited with notes and additions by Edward T. Reichert, M.D., 
Demonstrator of Experimental Therapeutics in Univ. of Penna In one handsome royal 
12mo. volume of 1030 pages, with 259 illustrations. Cloth, $1 50. Leather, $2 00 
(Just Ready.) 

American Editor's Preface. 

The high reputation acquired on both sides of the Atlantic by Dr. Foster's "Text-Book on 
Physiology," as a lucid exposition of functional physiology, in its most modern aspect, has seemed 
to call for an edition more thoroughly adapted to the wants of the American student. The plan 
of the author has presupposed an acquaintance with the details of physiological anatomy such as 
the student is accustomed to look to in his treatises on physiology. The absence of these 
details has rendered many parts of the work vague, il not altogether incomprehensible, and has 
therefore proved a serious drawback to the usefulness of the book as an accompaniment to lec- 
tures on physiology, as it is usually taught in our schools, and this deficiency the editor has 
endeavored to supply, by brief notes and the introduction of a large number of illustrations. 

The almost limitless amount of material accumulated by modern research has rendered diffi- 
cult the task of selection and compression, wi hout exceedirg the reasonable limits of a conve- 
nient text-book. In his selection the editor has been guided by his experience in the wants of 
students, and has endeavored merely to present, in the most concise form, such facts as would seem 
to be indispensable to a correct appreciation of the structure and function of the important 
organs. In accomplishing this, his additions have considerably exceeded his expectations, 
amounting to about 140 pages, including the illustrations which have been increased in number 
fioin 72 to 259 If he shall thus have succeeded in rendering this admirable work better fitted 
for the wants of the American student, he will feel abundantly rewarded. 

Nothing has been omitted from the English edition, and all additions have been distin- 
guished by insertions in brackets [ — J. 



The great popularity of "Foster's T»xt-book ofi simply a cursory reading. The work is well illus- 
Phy:>iology," both in England and in this country, 
readers it unnecessary to say anything further re- 
garding its ineiit. We shall, therefore, simply 
out that, in the American edition, numerous 



important additions have been made to the text of 
the third English edition whereby tbe usefulness of 
the work as a text-book for students has been greatly 
increased.— Phila. Med. and Surg. Reporter, April 
21, 18S0. 

Foster's Physiology is a most excellent book, not 
only tor the student, but especially for the physician 
who wishes to revise and increase his physiological 
knowledge. The style of the author is ciear, his ar- 
rangement and classification of subjects very satis- 
fttctorv and he has presented in this volume a most 
valuable exposition of physiology as now known.— 
The Am. Practitioner, April, 1880. 

Every sentence shows careful and mature thought, 
and the student, at the outset, will have to make up 
his mind that Foster's work requires study, and not 



trated, and its method clear and logical, and eini 
neutly practical, and fully up to tbe present aa- 
vaaced status of this most important branch of 
medicine. Foster's tvork is a credit to his scholar- 
ship and research, and will be accepted every wheie 
by the student and practitioner as reliable authority. 
It should be in the hands of every medical studeut. 
— St. Louis Olin. Record, April, 1S80. 

The matter of the last English edition has b»e» 
transferred bodily to this, aud there have been 
added very masy illustrations and copious notes 
on histology an i embryology by the American edit- 
or. The English editions have been defective, so 
far as Ameruaa sudents are concerned, in the'r 
dearth of illustrations and the absence of all discus- 
sion of physiological anatomy. Th^se being .-up. 
plied in this edi ion, the work is now undoubtedly 
tne best on physiology in the English language. — 
Ohio Med. Recorder, June, 1880. 



THE SAME. English Student's Edition, without notes or additions. 

Latest i sue. In one small 12mo. volume of 804 pages with 72 illustrations. Cloth, 75 cts. 



Henry C. Lea's Son & Co.'s Publications — (Physiology, Chemistry). 9 



nALTON [J. C.), M.D., 

•*-J Professor of Physiology in the College of Physicians and Surgeons, New York, &o . 

A TREATISE ON HUMAN PHYSIOLOGY. Designed for the use 

of Studentsand Practitioners of Medicine. Sixth edition, thoroughly revised and enlarged, 
with three hundred and sixteen illustrations on wood. In one very beautiful octavo vol- 
ume, of over 800 pages. Cloth, $5 50; leather, $6 50; half Russia, $7. (Just Issued.) 



During the past few years several new works on phy- 
siology, and new editions of old works, have appeared, 
competing for the favor of the medical student, hut 
none will rival this new edition of Dalton. As now en- 
larged, it will be found also to be, in general, a satisfac- 
tory work of reference for the practitioner. — Chicago 
Med. Journ. and Examiner, Jan. 1876. 

Prof. Dalton has discussed conflicting theories and 
conclusions regarding physiological questions with a 
fairness, a fulness, and a conciseness which lend fresh- 
ness and vigor to the entire book. But his discussions 
have been so guarded by a refusal of admission to those 
speculative aud theoretical explanations, which ai best 
exist in the minds of observers themselves as only pro- 
babilities, that none of his readers need be led into 
grave errors while making them a study. — The Medical 
Record, Feb. 19, 1876. 

The revision of this great work has brought it forward 
with the physiological advances of theday. and renders 
it, as it has ever been, the finest work for students ex- 
tant. — Nashville Journ. of Med. and Surg., Jan. 1876. 

For clearness and perspicuity, Dal ton's Physiology 
commended itself to the student years ago. and was a 
pleasant relief from the verbose productions which it 
supplanted. Physiology has. however, made many ad- 
vances since then — and while the style has been pre- 
served intact, the work in the present edition has been 
brought up fully abreast of the times. Thenew chemical 
notation and nomenclature have also been introduced 
into the present edition. Notwithstanding the multi- 
plicity of text-books on physiology, this will lose none 



of its old time popularity. The mechanical execution 
of the work is all that could be desired. — Peninsular 
Journal of Medicine, Dec. 1875. 

This popular texi-book on physiology comes to us in 
its sixth edition with the addition of about fifty per cent. 
of new matter, chiefly in the departments of patho- 
logical chemistry and the nervous system, where the 
principal advances have been realized. With so tho- 
rough revision and additions, that keepthe work well 
up to the times, its continued popularity may be confi- 
dently predicted, notwithstanding the competition it 
may encounter. The publisher's work is admirably 
done. — St. Louis Med., and Surg. Journ , Dec. 1875. 

We heartily welcome this, the sixth edition of this 
admirable text book, than which there are none of equal 
brevity more valuable. It is cordially recommended by 
the Professor of Physiology in the University of Louisi- 
ana, as by all competent teachers in theUnited States, 
and wherever the English language is read, this book 
has been appreciated. The present edition, with its 316 
admirably executed illustrations, has been carefully 
revised and very much enlarged, although its bulk does 
not seem perceptibly increased. — New Orleans Medical 
and Surgical Journal , March, 1876. 

The present edition is very much superior to every 
other, not only in that it brings the subject up to the 
times, but that it does so more fully and satisfactorily 
than any previous edition. Takeitai together it remains 
inourhumbleopinion,thebest text book on physiology 
in any land or language. — The Clinic, Noy. 6, 1875. 



QREENE [WILLIAM H.), M.D., 

^ Dernonstrntor of Chemistry in Med. Dept , Univ. of Penna. 

A MANUAL OF MEDICAL CHEMISTRY. For the Use of Students. 

Based upon Bowman's Medical Chemistry. In one royal 12mo. volume of 312 pages. 
With illustrations. Cloth, $1 75. (Just Issued.) 



It U well written, and gives the latest views on 
vital chemistry, a subject with which nnst physi- 
cians are not sufficiently familiar. To those who 
may wish to improve their knowledge in that direc 
tion, we can heartily recommend this work as beiDg 
worthy of a carefal perusal. — Phila. Med. and Surg. 
Reporter, April 24, 1SS0. 



The little work before ns is one which we think 
will be studied with pleasure and profit The de- 
scrintions. though brief, are clear, and in most cases 
sufficient for the purpose This book will, in nearly 
all cases, meet general approval. — Am. Journ. of 
Pharmacy, April, 18S0. 



fILASSEN (ALEXANDER), 

V^ Professorin the Royal Polytechnic School, Aix la-Chapelle. 

ELEMENTARY QUANTITATIVE ANALYSIS. Translated with 

notes and additions by Edgar F. Smith, Ph.D., Assistant Prof, of Chemistry in the 
Towne Scientific School, Univ. of Penna. In one handsome royal 12tno. volume, of 324 
pages, with illustrations; cloth, $2 00. (Just Ready.) 

It is probably the best manual of an elementary | advancing to the analysis of minerals and such pro- 
nature extant, insomuch as its methods are the best, ducts as are met with in applied chemistry. It is 
It teaches by examples, commencing with single an indispensable book for students in chemistry.—' 
determinations, followed by separations, and then I Boston Journ. of Chemistry, Oct. 187S. 

fj. ALLOW AY (ROBERT), E.C.S., 

V? Prof of Applied Chemistry in the Royal College of Science for Ireland, etc. 

A MANUAL OF QUALITATIVE ANALYSIS. From the Fifth Lon- 
don Edition. In one neat royal 12mo. volume, with illustrations ; cloth, $2 75. (Lately 
Issued.) 

J^EMSEN(IRA), M.D., Ph.D., 

Professor of Chemistry in the Johns Hopkins University, Baltimore. 

PRINCIPLES OF THEORETICAL CHEMISTRY, with special reference 

to the Constitution of Chemical Compounds. In one handsome royal 12mo. vol. of over 
232 pages: cloth, $1 50. (Just Issued.) 



BOWMAN'S INTRODUCTION TO PRACTICAL 
CHEMISTRY, INCLUDING ANALYSIS. Sixth 
Amencau, from the sixth and revised London edi- 
tion. With numerous illustrations. In one neat 
vol., royal 12mo., cloth, $2 25. 

WOHLER AND FITTIG'S OUTLINES OP ORGANIC 
CHEMISTRY Translated with additions from the 
Eighth German Edition. By Ira Remsex. M D , 
Ph.D., Prof, of Chemistry and Physics in Williams 



College, Mass. In one volume, royal 12mo. of 550 
pp , cloth, $3. 

LEHMANN'S MANUAL OF CHEMICAL PHYSIOL- 
OGY. Translated from the German, with Notes 
and Additions, by J. Cheston Morris, M.D. With 
illustrations on wood. In one octavo volume of 
336 pages. Cloth, $2 25. 

LEHMANN'S PHYSIOLOGICAL CHEMISTRY. Com- 
plete in two large octavo volumes of 1200 pages, 
with 200 illustrations; cloth, $6. 



10 Henry C. Lea's Son & Co.'s Publications — (Chemistry). 



POWNES {GEORGE), Ph.D. 

A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and 

Practical. Revised and corrected by Henry Watts, B.A., F R.S., authorof "A Diction- 
ary of Chemistry," etc. With a colored plate, and one hundred and seventy-seven illus- 
trations. A new American, from th< twelfth and enlarged London edition. Edited by 
Robert Bridges. M.D. In one larpe royal 12mo. volume, of over 1000 pages; 
cloth, $2 75; leather, $3 25. (Jtist Issued.) 
Two careful revisions by Mr. Watts, since the appearance of the last American edition of 
" Pownes," have soenlarged the work that in England it has been divided into two volumes. In 
reprinting it, by the use of a sraa'l and exceedingly clear type, cast for the purp- se, it has been 
found possible to comprise the whole, without omission, in one volume, not unhandy for study and 
reference. The enlargement of the work has induced the A merican Editor to confine his additions 
to the narrowest compass, and he has accordingly inserted only such discoveries as have been an- 
nounced since the very recent appearance of the work in England, and has added the standards 
in popular use to the Decimal and Centigrade systems employed in the original. 

Among the additions to this edition will be found a very handsome colored plate, representing 
a number of spectra in the spectroscope. Every care has been taken in the typographical execu- 
tion to render the volume worthy in every respect of its high reputation and extended use, and 
though it has been enlarged by more than one hundred and fifty pages, its very moderate price 
will still maintain it as one of the cheapest volumes accessible to the chemical student. 



This work, inorganic and orgauic, is complete in 
one convenient volume. In lip earliest editions it 
was fully up to the latest advancements and theo- 
ries of that time. In its present form, it presents, 
in a remarkably convenient and satisfactory man- 
ner, the principles and leading facts of thecbemistrj 
of to-day. Concerning the manner in which the 
various subjects are treated, much deserves to be 
said, and mostly, too, in praise of the book. A re- 
view of such a work af Fo tones' s Chemistry within 
the limits of a book-notice for a medical weekly is 
simply out of the question. — Cincinnati Lancet and 
Clinic, Dpc 14, 1878. 

When we state that, in our opinion, the present 
edition sustains in every respect the high reputation 
which its predecessors have acquired and enjoyed, 
we express therewiih our fall belief in iis intrinsic 
value as a text-book and work of reference. — Am. 
Journ. of Pharm., Aug. 1878. 

The conscientious care which has been bestowed 
upon it by the American and English editors renders 
it still, perhaps, the best book for the student and the 
practitioner who would keep alive the acquisitions 
of his student days. It has, indeed, reached a some- 



what formidable magnitude with its more than a 
thousand pages, but with less than this no fair repre- 
sentation of chemistry as it now is can be given. The 
type is small but very clear, and the sections are very 
lucidly arranged to facilitate study and reference.— 
Med and Surg. Reporter, Aug 3, 1878. 

The work is too well known to American students 
to need any extended notice; suffice it to say that 
the revision by the English editor has been faithfully 
done, and that Professor Bridges has added some 
fresh and valuable matter, especially in the inor- 
ganic chemistry. The book has always been a fa- 
vorite in this country, and in its new shape bids 
fair to retain all its former prestige. — Boston Jour, 
of Chemistry, Aug. 1878. 

It will be entirely unnecessary for us to make any 
remarks relating to the general character of Fownes' 
Manual For over twenty years it has held the fore- 
most place as a text-book, and the elaborate and 
thorough revisions which have been made from time 
to time leave little chance for any wide awake rival to 
step before it. — Canadian Pharm. Jour., Aug. 1878. 

As a manual of chemistry it is without a superior 
in the language.— Md. Med. Jour., Aug. 1878. 



A TTFIELD {JOHN), Ph.D., 

■"- Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, Ac. 

CHEMISTRY, GENERAL, MEDICAL, AND PHARMACEUTICAL; 

including the Chemistry of the U. S. Pharmacopoeia. A Manual of the General Principles 
of the Science, and their Application to Medicine and Pharmacy. Eighth edition revised 
by the author. In one handsome royal 12mo. volume of 700 pages, with illustrations. 
Cloth, $2 50 ; leather, $3 00. (Just Ready.) 

of chemistry in all the medical colleges in the 
United States. The present edition contains such 
alterations and additions as seemed necessary for 
the demonstration of the latest developments of 
chemical principles, and the latest, applications of 
chemistry to pharmacy I: is scarcely necessary 
for us to say that it exhibits chemistry in its pre- 
sent advanced state. — Cincinnati Medical Ntws, 
April, 1S79-. 

The popularity which this work has enjoyed is 
owing to the original and clear disposition of the 
facts of the science, the accuracy of the details, and 
the omission of much which freights many treatises 
heavily without briugingcorrespondinginstruction 
to the reader. Dr. Attfield writes for students, and 
primarily for medical students ; he always has an 
eye to the pharmacopoeia and its officinal prepara- 
tions; and be is continually putting the matter in 
the text so that it responds to the questions with 
which each section is provided. Thus the student 
learns easily, and can always refresh and test his 
knowledge.— Med a^d Surg. Reporter, April 19, '79. 

We noticed only about two vears and a half ago 
the publication of the preceding edition, and re- 
marked upon the exceptionally valuable character 
of the work. The work now i deludes the whole of 
the chemistry of the pharmacopoeia of the United 
States, Great Britain, and India. — New Remedies, 
May, 1879. 



We have repeatedly expressed our favorable 
opinion of this work, and on the appearance of a 
new edition of it, little remains for us to say, ex- 
cept that we expect this eighth edition to be as 
indispensable to us as the seventh and previous 
editions have been. While the general plan and 
arrangement have been adhered to, new matter 
has been added covering the observations made 
since the former edition The present differs from 
the preceding one chiefly in these alterations and 
in about ten pages of useful tables added in the 
appendix — Am. Jour, of Pharmacy, May, 1879. 

A standard work like Attfield's Chemistry need 
only be mentioned by its name, without further 
comments The present edition contains such al 
terations and additions as seemed necessary for 
the demonstration of the latest developments of 
chemical principles, and the latest applications of 
chemistry to pharmacy. The author has bestowed 
arduous labor on the revision, and the extent of 
the information thus introduced may be estimated 
from the fact that the index '-outains three hun- 
dred new references relating to additional mater- 
ial. — Druggists' Circular and Chemical Gazette. 
May, 1879. 

This very popular and meritorious work has 
now reached its eighth edition, which fact speaks 
in the highest terms in commendation of its excel- 
lence. It has now become the principal text-book 



Henry C. Lea's Son & Co.'s Publications — {Chemistry). 



11 



B 



LOXAM IG.L.), 

Professor of Chemistry in King's College, London. 

CHEMISTRY, INORGANIC AND ORGANIC. From the Second Lon- 

don Edition. In one very handsome octavo volume, of 700 pages, with about 300 illus- 
trations. Cloth, $4 00 j leather, $5 00. (Lately Issued.) 



We have in this work a completeand most excel- 
lent text-book for the use of schools, and can heart- 
ily recommend it as such. — Boston Med. and Surg. 
Journ., May 28, 1874. 

The above is the title of a work which we can most 
conscientiously recommend to students ot chemis- 
try. It is a6 easy as a work on chemistry could be 
made, at thesame time that it presents a full account 
of thatscience as it now stands. We have spoken 
of the work as admirably adapted to the wants- of 
students; it is quite as well suited to the require- 
ments of practitioners who wish to review their 
chemistry, or have occasion to refresh their memo- 
ries on any point relating to it. In a word, it is a 
book to be read by all who wish to know what is 
the chemistry of the presentday. — American Prac- 
titioner, Nov. 1873. 



It would be difficult for a practical chemist and 
teacher to find any material fault with this most ad- 
mirable treatise The author has given us almost a 
C) clopsedia within the limits of a convenient volume, 
and has done so without penning ihe useless para- 
graphs too commonly making up a great part of the 
bulk of many cumbrous works. The progressive 
scientist is not disappointed when he looks for the 
record of new and valuable proces.-es acd discover- 
ies, while the cautious conservative does not find its 
pages monopolized by uncertain theories and specu- 
lations. A peculiar point of excellence is the crys- 
tallized form of expression in which great truths are 
expressed in very short paragraphs. One is surprised 
a t the brief space allotted to an important topic, and 
yet, after reading it, he feels that little, if any more 
should have been said. Altogether, it is seldom yon 
see a text-book so nearly faultless. — Cincinnati 
Lancet Nov. 1873. 



ffLO WES (FRANK), D.Sc, London. 

v Senior Science- Master at the High School, Newcastle-tin der Lyme, etc. 

AN ELEMENTARY TREATISE ON PRACTIC AL CHEMISTRY 

AND QUALITATIVE INORGANIC ANALYSIS. Specially adapted for Use in the 

Laboratories of Schools and Colleges and by Beginners. From the Second and Revised 

English Edition, with about fifty illustrations on wood. In one very handsome royal 

12mo. volume of 372 pages : cloth $2 50. (Just Issued.) 

It is short, concise, and eminently practical. We [ are so simple, and yet concise, as to be interesting 

therefore heartily commend it to students, and e a pe- and intellig : ble. The work is unincumbered with 

cially to those who are obliged to dispense with a i theoretical deductions, dealing wholly with the 

master. Of course a teacher is in every way desi- i practical matter, which it is the am rf this compre- 



rable, but a good degree of technical skilland prac- 
tical knowledge can be attained with no other 
instructor than the very valuable handbook now 
under consideration. — St. Louis Clin. Record, Oct. 
1877. 

The work is so written and arranged that it can be 
comprehended by the student without a teacher, and 
the descriptions and directions forthe various work 



nsive text-book to impart. The accuracy of the 
analytical methods are vouched for fruni the fact 
that they have all been worked through by the 
author and the members of his cass. from the 
printed text. We can heartily recommend the work 
to the student of chemistry as being a reliable and 
comprehensive one. — Druggists'' Advertiser, Oct. 
15, 1877. 



KNAPP'S TECHNOLOGY; or Chemistry Applied to 
the Arts, and to Manufactures. With American 
additions by Prof. Walter R. Johnson. In two 



very handsome octavo volumes, with 500 wood 
engravings, cloth, $6 00. 



pARRISH [ED WARD), 

Late Professor of Materia Medica in the Philadelphia College of Pharmacy. 

A TREATISE ON PHARMACY. Designed as a Text-Book for the 

Student, and as a Guide for the Physician and Pharmaceutist. With many Formulae and 
Prescriptions. Fourth Edition, thoroughly revised, by Thomas S. Wiegand. In one 
handsome octavo volume of 977 pages, with 280 illustrations ; cloth, $5 50 ; leather, $6 50; 
half Russia, $7. (Lately Issued.) 
Of Dr Parrish's great work on pharmacy it only l the work, not only to pharmacists, but also to the 
remains to be said that the editor has accomplished | multitude of medical practiiioners who are obliged 
his work so well as to maintain, in this fourth edi-| tocompound their own medicines. It will ever hold 
tion, the high standard of excellence which it had | an honored place on our own bookshelves. — Dublin 
attained in previous editions, under the editorship of 
its accomplished author. This has not been accom- 
plished without much labor, and many additions and 



improvements, involving changes in the arrange- 
ment of rhe several parts of the work, and the addi- 
tion of much new matter. With the modifications 
thus effecteditconstitutes,as nowpresented 



Med. Press and Circular, Aug. 12, 1874. 

We expressed our opinion of a former edition in 
terms of unqualified praise, and we are in no mood 
to detract from that opinion in reference to the pre- 
sent edition, the preparation of which has fallen into 
competent hands. Itis a book with which no pharma- 



pendium of the science and art indispensable to the! «*?J can dispense and from which no physician can 
pharmacist, and of the utmost value to every i fai1 fc ? derive much information of value to him in 



practice. — Pacific Med and Surg . Journ. , June, '74. 

Perhaps one, if not the most important book upon 
pharmacy which has appeared in the English lan- 
guage has emanated from the transatlantic press. 
"Parrish's Pharmacy" is a well-known work on this 
side of the water, and the fact shows us that a really 
useful work neverbecomes merely local in its fame. 
Thanks to the judicious editing of Mr. Wiegand, the 
lisher. It will convey someidea of the liberality which posthumous edition of "Parrish" has been saved to 
has been bestowed upon its production when we men- the public with all the mature experience of its au- 
tion that thereare no less than 2S0carefully executed [ thor. and perhaps none the worse for a dash of new 
illustrations. In conclusion, we heartily recommend blood. — Lond. Pharm. Journal, Oct. 17, 1874. 



practitioner of medicine desirous of familiarizing 
himself with the pharmaceutical preparation of the 
articles which he prescribes for his patients. — Chi- 
cago Med. Journ., July, 1874. 

The work is eminently practical, and has the rare 
merit of beingreadableandinteresting, while itpre- 
serves astrictly scientificcharacter. The whole work 
reflects the greatest credit on author, editor and pub 



12 Henry C. Lea's Son <fe Co.'s Publications — (Mat. Med. and Therap.). 
JPARQUHARSON {ROBERT), M.D., 

Lecturer on Materia Medico, at St. Mary's Hospital Medical School. 

A GUIDE TO THERAPEUTICS AND MATERIA MEDICA. Pe- 

cond American edition, revised by the Author. Enlarged aod adapted to the U. S. 
Pharmacopoeia. By Fkank Woodbury, M.D. In one neat rojal 12ino. volume of 498 
pages: cloth, $2.25. (Just Ready.) 



The appearance of a new edition of this conve- 
nient and handy hook in .less than two years may 
certainly be taken as an indication of its useful 
ness. Its convenient arrangement, and its terse- 
ness, and, at the same time, comole'eness of the 
information given, make it a handy book of refer- 
ence. — Ant,. Joum. of Pharmacy, June, 1879. 

This work contains in moderate compass such 
well-digested facts concerning the physiological 
and therapeutical action of remedies as are reason- 
ably established up to the present time. By a con- 
venient arrangement the conespondirg effects of 
each article in health and disease are presented in 
parallel c< lumns, not only rendering reference 
easier, but also impressing the facts more strongly 
upon the mind of the reader. The book has been 
adapted to the wants of the American student, and 



copious notes have been introduced, embodying the 
latest revision of t*"e Pharmacopoeia, together wi'h 
the antidotes to the more prominent poisons, and 
such of the newer remedial agents as seemed neces- 
sary r,o the completeness of the work. Tables of 
weights and measures, and a good alphabetical in- 
dex end the volume. — Druggists' 1 Circular and 
Chemical Gazette, June, 1879. 

It is a pleasure to think that the rapidity with 
which a second edition is demanded may be taken 
as an indication that the sense of appreciation of the 
value of reliable information regarding the use of 
remedies i* notentirely overwhelmed in the cultiva- 
tion of pathological studies, characteristic of the pre- 
sent day. This work certainly merits the success it 
has so quickly achieved. — New Remedies, July, '79. 



OTILLE {ALFRED), M.D., 

Professor of Theory and Practice of Medicine in the University of Penna. 

THERAPEUTICS AND MATERIA MEDICA ; a Systematic Treatise 

on the Action and Uses of Medicinal Agents, including their Description and History. 
Fourth edition, revised and enlarged. In two large and handsome 8vo. vols, of about 2000 
pages. Cloth, $10; leather, $12; half Russia, $13. (Lately Isstied.) 

It is unnecessary to do much more than to an- 
nounce the appearance of the fourth edition of this 
well known aud excellent work. — Brit, and For. 
Med.-Chir. Review, Oct 1875. 

For all who desire a complete work on therapeutics 
aud materia medicafor reference, in casebiuvolving 
medico-legal questions, as well as for information 
concerning remedial agents, Dr. Still^'s is "par ex- 
cellence" the work. The work beingout of print, by 
the exhaustion of former editions, the au thor has laid 
the profession under renewed obligations, by the 
careful revision, important additions, and timely re 
issuing a work not exactly supplemented by any 
other in the English language, if in any language. 
The mechanical execution handsomely sustains the 
well-known skill and good taste of the publisher. — 
St. Louis Med. and Surg. Journal, Dec 1874. 

From the publication of the first edition "Stillg's 
Therapeutics" has been one of the classics; its ab- 
sence from our libraries would create a vacuum 
which could be filled by no other work in the lan- 
guage, and its presence supplies, in the two volumes 



of the present edition, a whole cyclopaedia of thera- 
peutics. — Chicago Medical Journal, V oh. 1875. 

The rapid exhaustion of three editions and the uni- 
versal favor with which the work has been received 
by the medical profession, are sufficient proof of its 
excellence as a repertory of practical and useful in- 
formation for the physician. The edition before us 
fully sustains this verdict, as the work has been care- 
fully revised and in some portions rewritten, bring- 
ing it up to the present time by the admission of 
chloral and crotonchloral, nitrite of amyl, bichlo- 
ride of methylene, methylic ether, lithium com- 
pounds, gelseminum, and other remedies. — Am. 
Joum. of Pharmacy, Feb. 1875. 

We can hardly admit that it has a rival in the 
multitude of its citations and the fulness of its re- 
search into clinical histories, and we must assign it 
a place in the physician's library; not, indeed, as 
fully representing the present state of knowledge in 
pharmacodynamics, but as by far the most complete 
treatise upon the clinical and practical side of the 
question. — Boston Med. and. Surg. Journal, N ov. 5, 
1S74. 



/GRIFFITH {ROBERT E.), M.D. 

A UNIVERSAL FORMULARY, Containing the Methods of Prepar- 

ing and Administering Officinal and other Medicines. The whole adapted to Physicians and 
Pharmaceutists. Third edition, thoroughly revised, with numerous additions, bj John M. 
Maisch, Professor of Materia Medicain the Philadelphia College of Pharmacy. In one large 
andhandsome octavo volume of about800pp., cl., $450 ; leather, $5 50. (Lately Issued.) 



To the druggist a good formulary is simply indis- 
pensable, and perhaps no formulary has been more 
extensively used than the well-known work before 
us. Many physicians have to officiate, also, as drug- 
gists. This is true especially of the country physi- 
cian, and a work which shall teach him the means 
by which to administer or combine his remedies in 
the most efficacious and pleasant manner, will al- 
ways hold its place upon his shelf. A formulary of 
this kind is of benefit also to the city physician in 
largest practice.— Cincinnati Qlinic, Feb. 21. 1S74. 



A more complete formulary than itis in its pres- 
ent form the pharmacist or physician could hardly 
desire. To the first some such work is indispensa- 
ble, and it is hardly less essential to the practitioner 
who compounds his own medicines. Much of what 
is contained in the introduction ought to be com- 
mitted to memory by every student of medicine. 
As a help to physicians it will be found invaluable, 
and doubtless will make its way into libraries not 
already supplied with a standard work of the kind. 
^-The American Practitioner, Louisville, July, '74. 



CHRISTISON'S DISPENSATORY. With copious ad- 
ditions, and 213 large wood engravings. By R. 
Eolesfield Griffith, M.D. One vol. 8vo., pp. 
1000, cloth. $4 00. 



CARPENTER'S PRIZE ESSAY ON THE USE OF 
Alcoholic Liquors in Health and Disease. New 
edition, with a Preface by D. F. Condte, M.D., and 
explanations of scientificwords. In oneneatl2mo. 
volume, pp. 178, cloth. 60 cents. 



Henry C. Lea's Son & Co.'s Publications — {Mat. Med. and Therap.). 13 



OTILLE {ALFRED), M.D., LL.D., and JhfAlSCH [JOHN M.). Ph.D., 

O Prof, of Theory and Practice of Medicine •*-*-*- Prof, of Mat. Med. and Hot. in Phil a. 

and of Clinical Med. in Univ. of Pa. Coll. Pharmacy. Secy, to the American 

Pharmaceutical Association. 

THE NATIONAL DISPENSATORY: Containing the Natural History, 

Chemistry, Pharmacy, Actions and Uses of Medicines, including those recognized in 
the Pharmacopoeias of the United States, Great Britain, and Germany, with numer- 
ous references to the French Codex. Second edition, thoroughly revised, with numerous 
additions. In one very handsome octavo volume of 1692 pages, with 239 illustrations. 
Extra cloth, $6 75 ; leather, raised bands, $7 50 ; half Russia, raised bands and open 
back, $8 25. (Now Ready.) 

Preface to the Secoxd Edition. 

The demand which has exhausted in a few months an unusually large edition of the National 
Dispensatory is doubly gratifying to the authors, as showing that t'ley were correct in th'nking 
that the want of such a work was felt by the medical and pharmaceutical professions, and that 
their efforts to supply that want have been acceptable. This appreciation of their labors has 
stimulated them in the revision to render the volume more worthy of the very marked favor 
with which it has been received. The first edition of a work of c uch magnitude must necessarily 
be more or less imperfect; and though but litt'e that is new and important has been brought 
to light in the short interval since its publication, yet the length of time during which it was 
passing through the press rendered the earlier portions more in arrears than the la er. The 
opportunity for a revision has enabled the authors to scrutinize the work as a whole, and to 
introduce alterations and additions whereve* there has seemed to be occasion for improve- 
ment or greater completeness. The principal changes to be noted are the introduction of seve- 
ral drugs under separate headings, and of a large number of drugs, chemicals, and pharma- 
ceutical preparations classified as allied drugs and preparations under the heading of more 
important or better known articles : these additions comprise in part nearly the entire German 
Pharmacopoeia and numerous articles from the French Codex. All new investigations which 
came to the authors 1 notice up to the time of publication have received due consideration. 

The series of illustrations has undergone a corresponding thorough revision. A number have 
been added, and still more have been substituted for such as were deemed less satisfactory. 

The new matter embraced in the text is equal to nearly one hundred pages of the first edition . 
Considerable as are these changes as a whole, they have been accommodated by an enlargement 
of the page without increasing unduly the size of the volume. 

While numerous additions have been made to the sections which relate to the physiological 
action of medicines and their use in the treatment of disease, great care has been taken to 
make them as concise as was possible without rendering them incomplete or obscure. The 
doses have been expressed in the terms both of troy weight and of the metrical system, for the 
purpose of making those who employ the Dispensatory familiar w.th the latter, and paving the 
way for its introduction into general use. 

The Therapeutical Index has been extended by about 2250 new references, making the total 
number in the present edition about 6000. 

The articles there enumerated as remedies for particular diseases are not only those which, 
in the authors' opinion, are curative, or even beneficial, but those also which have at any time 
been employed on the ground of popular belief or professional authority. It is often of as 
much consequence to be acquainted with the worthlessness of certain medicines or with the 
narrow limits of their power, as to know the well attested virtues of others and the conditions 
under which they are displayed An additional value posse sed by such an Index is, that it 
contains the elements of a natural classification of medicines, founded upon an analysis of the 
results of experience, which is the only safe guide in the treatment of disease. 

This evidence of success, seldom paralleled, intend to let the grass grow under their feet, but to 
shows clearly how well the authors have met the keep the work up to the time. — New Remedies, Nov. 
existing needs of the pharmaceutical and medical 187.9. 

professions. Gratifying as it must be to them, they TbJs is a t work b tw0 of the ab]est writer8 on 

have embraced the oppor unity offered for a thor- j materia m * dica in Am / ri , a The 9Uth0 rs h-ve pro- 
ough revision of the whole work, striving to era- duced a work which for aceuracy and com prehensiYe- 
brace within it all that might have been omitted in . g unsurpassed by any work on th , sabject . There 

the former edition, and all that has newly appeared is n0 book in the Kns i ish i anguage *hich contains so 
of sufficient importance during the time of its col- I much Taluable information on the various articles of 
laboration, and the short interval elapsed since the ! the materia medica . The work has cost t he authors 
previous publication. After having gone carefully j s of laborious study but tbey have succeeded in 

through the volume we must admit that the authors I produciag a dispensatory which is not only national, 
have labored faithfully, and with success, in main- butwill be a i ast ing memorial of the learning and 
taming the high character of their work as a com- abllitv of the authors who pro duced it.-Edinburgh 
pendium meeting the requirements of the day, to ! M(ldi ^ journal, Nov. 1879. 



which one can safely turn iD quest of the latest in- j 
formation concerning everything worthy of notice in 
connection with Pharmacy, Materia Medica, and 
Therapeutics. — Am. Jour, of Pharmacy, Nov. 1879. 
It is with great pleasure that we announce to our 
readers the appearance of a second edition of the 
National Dispensatory. The total exhaustion of the 
first edition in the short space of six months, is a 
sufficient testimony to the value placed upon the 
work by the profession. It appears that the rapid 
sale of the first edition must have induced both the 
editors and the publisher to make preparations for 
a new edition immediately after the first had been 
issued, for we find a large amount of new matter 
added and a good deal of the previous text altered 
and improved, which proves that the authors do not 



It is by far more international or universal than 
any other book of the kind in our language, and 
more comprehensive in every sense.— Pacific Med. 
and Surg. Jou**n., Oct. 1S79. 

The National Dispensatory is beyond dispute the 
very best authority. It is throughout complete in 
all the necessary details, clear and lucid in its ex- 
planations, and replete with references to the most 
recent writings, where further particulars can be 
obtained, if desired. Its value is greatly enhanced 
by the extensive iudices — a general in ex of materia 
medica, etc., and also an index of therapeutics It 
would be a work of supererogation to say more about 
this well-known work. No practising physician can 
afford to be without the National Dispensatory. — 
Canada Med. and Surg. Journ., Feb. 18S0. 



14 Henry C. Lea's Son & Co.'s Publications — (Pathology, &c). 



ffORNIL (V.), AND 

^ Prof, in the Faculty of Med , Paris 



JDANVIER (L.), 

■*- *» Prof in the College of France. 

MANUAL OP PATHOLOGICAL HISTOLOGY. Translated, with 

Notes and Additions, by E. 0. Shakespeare, M.D., Pathologist and Ophthalmic Surgeon 
to Pbilada. Hospital, Lecturer on Refraction and Operative Ophthalmic Surgery in Univ. 
of Penna., and by Henry C. Simes M D., Demonstrat- r of Pathological Histology in 
the Univ. of Pa. In one very handsome octavo volume of over 700 pages, with over 
350 illustrations. Cloth, $5 50; leather, $6 50; half Russia, $7. (Just Ready.) 
The work of Cornil and Rangier is so well known as a lucid and accurate text book on its 
important subject, that no apology is needed in presenting a translation of it to the American 
profess ; on. It is only necessary to say that the labors of Drs. Shakespeare and Simes have 
been by no means confined to the task of rendering the work into English. As it appeared in 
France, in successive portions, between 1868 and 1876, a part of it, at least, was somewhat in 
arrears of the present state of science, while the diffuseness of other portions rendered conden- 
sation desirable. The translators have, therefore, sought to bring the work up to the day, 
and, at the same time, to reduce it in size, a; far as pract r cable, without i n^airing its com- 
pleteness These changes will be found throughout the volume, the most extensive being in 
the sections devoted to Sarcoma, Carcinoma, Tuberculosis, the Bloodvessels, the Mammae, and 
the classification of tumors Corresponding modifications have been made in the very exten 
sive and beautiful series of illustrations, and every care has been taken in the typographical 
execution to render it one of the most attractive volumes which have issued from the American 
press. 



The translators have done their work very well 
indeed, reudering it into smooth and excellent Eng- 
lish, and in their selection of new material they 
have in the main used good discrimination. We 
heartily commend the book as one of the best works 
on the subject. — Boston Med. and Surg. Journal, 
March 11, 1880. 

Their bo *k is not a collection of the work of others, 
but has been written in the laboratory beside the 
microscope. It bears the marks • f personal knowl- 
edge and investigation upon every page, controlled 
by and controlling the work of others. ... In 
short, its translation has made it the best work in 
pathology attainable in our language, one that every 
student, certainly, ought to have. — Archives of Med- 
icine, April, 18S0. 

This work, in the original, has for years past 
occupied a prominent place in the library of French 
pathologists, as we should naturally be led to be- 
lieve from the reputation of the distinguished au- 
thors. Now that it has been presented to the Eng- 
lish student for the first time, it will be perused 



with unusual interest. The illustrations are by no 
means the least valuable part of the work. Indis- 
pensable as they are to any work of this nature, 
in the work before us the artist has succeeded in 
producing cuts which will prove unusually valuable 
to the reader. The translation is well done, and 
gives evidence throughout the volume that it was 
made by a person thoroughly conver.-aut with the 
subject.— N. Y. Med. Gazette, Feb. 28, 1880. 

This will be found an exceedingly interesting 
and valuable work by all who are engaged in the 
study of or take an interest in, histology — normal 
or morbid. The material which was utilized in its 
preparation was derived from autop-ies and opera- 
tions in the hospitals of Paris, which are so very 
rich in it. No'hing was taken for granted, but 
everything verified by microscopical investigation 
by the authors themselves in their own laboratories 
assisted by their pupils. As an aid to microscopists 
in (heir investigations it will be found invaluable — 
in fact, the very best with which we are acquainted. 
— Cincinnati Med. News, February, 1880. 



F 



G 



ENWICK (SAMUEL), M.D., 

Assistant Physician to the London Hospital* 

THE STUDENT'S GUIDE TO MEDICAL DIAGNOSIS. From the 

Third Revised and Enlarged English Edition. With eighty-four illustrations on wood. 
In one very handsome volume, royal 12mo. , cloth, $2 25. (Just Issued.) 

REEN (T. HENRY), M.D., 

Lecturer on Pathology and Morbid Anatomy at Charing-Cross Hospital Medical School, etc. 

PATHOLOGY AND MORBID ANATOMY. Third American, from 

the Fourth and Enlarged and Revised English Edition. In one very handsome octavo 
volume of 332 pages, with 132 illustrations; cloth, $2 25. (Now Ready.) 

ciently numerous, and usual'y well made. In the 
p e>-ent edition, such new matter has been added as 
was necessary to embrace the later results iu patho- 
logical research. No doubt it will continue to enjoy 
the favor it has received at the hands of the profes- 
sion. — Med and Surg. Reporter, Feb. 1, 1879. 



This is unquestionably one of the best manuals on 
the subject of pathology and morbid anatomy that 
can be placed in the student's hands, and we are 
glad to see it kept up to the times by new editions. 
Each edition is carefully revised by the author, with 
the view of making it include the most recent ad- 
vances in pathology, and of omitting whatever may 
have become obsolete. — N. ¥. Med. Jour., Feb. 1879. 

The treatise of Dr. Green is compact, clearly ex- 
pressed, up to the times, and popular as a text-book, 
both in England and America. The cuts are suffi- 



For practical, ordinary daily use, this is undoubt- 
edly the best treatise that is offered to students of 
pathology and morbid anatomy. — Cincinnati Lan- 
cet and Clinic, Feb. 8, 1879. 



GLUGE'S ATLAS of PATHOLOGICAL HISTOLOGY 
Translated, with Notes and Additions, by Joseph 
Leioy, M. D. In one volume, very large imperial 
quarto, with 320 copper-plate figures, plain and 
colored, cloth. $4 00 

PAVY'S TREATISE ON THE FUNCTION OF DI- 
GESTION: its Disorders and their Treatment. 
From the second London edition In one hand- 
some volume small octavo, cloth, $2 00. 

LA ROCHE ON YELLOW FEVER. considered in its 
Historical, Pathological. Etiological, and Thera 
peutical Relations. In two large and handsome 
octavo volumes of nearly 1500 pp., cloth. $7 00. 



aOLLAND'S MEDICAL NOTES AND REFLEC- 
TIONS. 1 vol. 8vo., pp. 500, cloth. $3 50. 

BARLOW'S MANUAL OF THE PRACTICE OF 
MEDICINE. With Additions by D. F. Condie 
M D. 1 vol. 8vo., pp 600. cloth. *2 50. 

TODD'SCLINICAL LECTURES on CERTAIN ACUTE 
Diseases. In one neat octavo volume, of 320 pp., 
cloth. $2 50. 

STOKES' LECTURES ON FEVER. Edited by John 
William Moore, M. D., Assistant Physician to the 
Cork Street Fever Hospital. In one neat Svo. 
volume cloth, $2 00. 



Henry C. Lea's Son & Co.'s Publications — (Practice of Medicine). 15 



fifLINT (AUSTIN), M.I)., 

*• Professor of the Principles and Practice of Medicine in Bellevue Med. College, N. Y. 

A TREATISE ON THE PRINCIPLES AND PRACTICE 

MEDICINE ; designed for the use of Students and Practitioners of Medicine. 

edition, revised and much improved. In one large and closely printed octavo volume of 

about 1100 pp. (Inpress ) 
A few notices of the previous edition are appended. 
This excellent treatise on medicine has acquired 
for itselfintheUnited States a reputation similar to 
thaten.ioyed in England by the admirable lectures 
of Sir Thoma6 Watson. We have referred to many 
of the most important chapters, and find the revi- 
sion spoken of in the preface is a genuine one, and 
that the author has very fairly brought up his matter 
to the level oft he knowledge of the present day. The 
work has this great recommendation, that it is in one 
volume, and therefore will not be so terrifying tothe 

student as the bulky volumes which several of our i teachings, have left it without a rival in the field. 
Englishtext-booksofmedicinehavedevelopedinto. #• Y.—Med Record, Sept. 15,1874. 
— British and Foreign Med-Chir. Rev., Jan . 1875 It ig given to very few men to tre ad in the steps of 

Itisof courseunnecessary tointroduce or eulogize Austin Flint, whose siDgle volume on medicine, 
this now standard treatise. The present edition j though hereand there defective, isa masterpiece of 
has been enlarged and revised to bring it up to the i lucid condensation and of general grasp of an enor- 
author's present level of experience and reading. I mously widesubject — Lond. Practitioner, Dec. '73. 



OF 

Fifth 



His own clinical studies and the latest contribu- 
tions to medical literature both in this country and 
in Europe, have received careful attention, so that 
some portions have been entirely rewritten, and 
about seventypages of new matter have been ad- 
ded. — Chicago M>-d Jour., June, 1873. 

Has never been surpassed as a text-book for stu- 
dents and a book of ready reference for practition- 
Theforce of its logic, its simple and practical 



D7 THE SAME AUTHOR. 

CLINICAL MEDICINE; a Systematic Treatise on the Diagnosis 

and Treatment of Diseases. Designed for Students and Practitioners of Medicine. In 
one large and handsome octavo volume of 795 pages; cloth, $4 50 ; leather, $5 50; 
half Russia, $6. {Now Ready.) 



It is here that: the skill and learning of the great 
clinician are displayed He has given us a store- 
house of medical knowledge, excellent for the stu- 
dent, convenient for the pracitioner, the result of a 
long life of the most faithful clinical work, collect- 
ed by an energy as v'gilant end systematic as un- 
tiring, and weighed by a judgment no less clear 
than his observation is close.— Archives of Medi- 
cine, Dec. 1S79 

The author of the above work has anticipated a 
want long felt by those for whom it was especially 
written— the ciinical student during his pupilage, 
and the busy practitioner. He has given to the 
medical profession a very necessary and useful 
work, complete in detail, accurate in observation, 
br ef in statement. — St. Louis Courier of Med., 
Oct 1S79. 

There is every reason to believe that this book 
will be well received. The active practitioner is 
frequently in need of some work that will enable 
him to obtain information in the diagnosis and 
treatment of cases with comparatively little labor. 
Dr. Flint has the faculty of expressing himself 



clearly, and at the same time so concisely as to 
enable the searcher to traverse the entire ground 
of his search, and at the same time obtain all that 
is essential, without plodding through an intermi- 
nab'e space.— N. Y. Med. Jour.. Nov. 1879 

The eminent teacher who has written the volume 
under consi leration h^s recognized the needs of 
the American profession, and the result is all that 
we could wish. The style in which it if written is 
peculiarly the author's ; it is clear and forcible, and 
marked by those characteristics which have ren- 
dered him one of the best writers and teachers this 
country has ever produced. We have not space for 
so full a consideration of this remarkable work as 
we would desire. — S. Louis Clin. Record, Oct. 1879. 

It is venturing little to say that there are few men 
so well fitted as Dr Flint to impart information on 
these last mentioned subjects, and the present work 
is a timely one as relates both to the author's ca- 
pacity to undertake it and the need for it as an 
accompaniment to the multitude now issued, in 
which the subject of treatment is but little consid- 
ered.— New Remedies, Nov. 1879. 



gY THE SAME AUTHOR. 

ESSAYS ON CONSERVATIVE MEDICINE AND KINDRED 

TOPICS. In one very handsome royal 12rao. volume. Cloth, $1 38. (Just Issued.) 



W: 



H 



'ATSON (THOMAS), M.D., get 

LECTURES ON THE PRINCIPLES AND PRACTICE OF 

PHYSIC. Delivered at King's College, London. A new American, from the Fifth re- 
vised and enlarged English edition. Edited, with additions, and several hundred illustra- 
tions, by Henry Hartshorne, M.D., Professor of Hygiene in the University of Penn- 
sylvania. En two large and handsome 8vo. vols. Cloth, $9 00 : leather, $11 00. (Lately 
Published.) 

ARTSHORNE (HENRY), M.D., 

Professor of Hygiene in the University of Pennsylvania 

ESSENTIALS OF THE PRINCIPLES AND PRACTICE OF MEDI- 
CINE. A handy-book forStudents and Practitioners. Fourth edition, revised and im- 
proved. With about one hundred illustrations. In one handsome royal 12mo. volume, 
of about 550 pages, cloth, $2 63 ; half bound, $2 88. (Lately Issued.) 



DAVIS'S CLINICAL LECTURES ON VARIOUS 
IMPORTANT DISEASES; being a collection of the 
Clinical L ctures delivered in the Medical Wards 
of Mercy H ospi al, Chicago. Edited by Fravk H 
Davis, M.D. Second edition, enlarged. In one 
handsome royal 12 no. volume. Cloth, $1 75. 

THE CYCLOPEDIA OF PRACTICAL MEDICINE: 
comprising Treatises on the Nature and Treatment 
of Diseases, Materia Medica and Therapeutics, Dis- 



eases of Women and Children, Medical Jurispru- 
dence, etc. etc. By Dr/NGLisoN, Forbes, Tweedte, 
and Conolly. In four large super-royal octavo 
volumes, of 3254 double-columned pnges, strongly 
and handsomely bound in leather, $15; cloth. $11. 
STURGES*S INTRODUCTION TO THE STUDY OF 
CLINICAL MEDICINE. Being a Guide to the In- 
vestigation of Disease. In one handsome 12mo. 
volume, cloth, $1 25. (Lately Issued.) 



16 Henry C. Lea's Son & Co.'s Publications — {Practice of Medicine). 
£>RISTOWE(JOHN SYER),M.D ., FR.C.P., 

J-) Physician and Joint Lecturer on Medicine., St. Thomas's Hospital. 

A TREATISE ON THE PRACTICE OF MEDICINE. Second 

American edition, revised by the Author. Edited, with Additions, by James H. Hutch- 
inson, MD., Physician to the Penna. Hospital. In one handsome octavo volume of 
nearly 1200 pages. With illustrations. Cloth, $5 00; leather, $6 00; half Russia, 
$6 50. (Now Ready.) 

The second edition of this excellent work, like the 
first, bas received the benefit of Dr. Hutchinson's 
annotations, by which the phases of disease which 
are peculiar to this country are indicated, and thus 
a treatise which was intended for British practi 
tioners and students is made more practically useful 
on this side of the water. We see no reason to 
modify the high opinion previously expressed with 
regard to Dr. Bristowe's work, except by adding 
our appreciation of the careful labors of the author 
in following the lateral growth of medical science. 
The chapter on diseases of the skin and of the nerv- 
ous system, with a new one on insanity compiled 
from tbe best sources outside of the author's own 
long experience, and the valuable portion relating 
to general pathology, aid greatly in completing an i Recorder, Jan. 7, 1880 



exceptionally good book for purposes of reference 
and ins ruction — Boston Medical and Surgical 
Journal, February, 1S80. 

The popularity of the work depends, no doubt, 
upon the clear and incisive way in which it is 
written, and the attention to details likely to occur 
in practice, rather than the discussion ol questions 
of theory. — New Remedies, Jan 1880. 

What we said of the first edition, we can, with 
increased emphasis, repeat concerning this: "Every 
page is cha racterized by the utterances of a thought- 
ful man. What has been said, has been well said, 
and the book is a fair reflex of all that is certainly 
known on the sub'ects considered."— Ohio Med. 



RICHARDSON {BENJ. W.), M.D., F.R.S., M.A., LL.D., F.S.A., 

-*-*' Fellow of the Royal College of Physicians, London. , 

PREVENTIVE MEDICINE. In one octavo volume of about 500 pages. 

(In Press.) 

The immense strides taken by medical science during the last quarter of a century have had 
no more conspicuous field of progress than the causation of disease. Not only has this led to 
marked advance in therapeutics, but it has given rise to a virtually new department of medi- 
cine — the prevention of disease — more important, perhaps, in its ultimate re ults than even the 
investigation of curative processes- Yet thus far there has been no attempt to gather into a 
systematic and intelligible shape the accumulation of knowledge tl us far acquired r»n this most 
interesting subject. Fortunately, the task hs been at last undertaken by a writer who of all 
others is, perhaps, best qualified for its performance, and the result of his labors can hardly fail 
to mark an epoch in the history of medical science. The plan adopted for the execution of this 
novel design can best be explained in his own words : — 

"With the object here expressed I write this volume. I have nothing: to say in it that has 
any relation to the cure of disease, but I base it revertheless on the curative side of medical 
learning In other words, I trace the diseases from their actual representation as they exist 
before us, in their natural progress after their birth, as far as I am able, back to their origins, 
and try to seek the conditions out of which they spring. Thereupon I endeavor further to 
analyze those conditions, to see how far they are removable and how far they are avoidable." 



WOODBURY {FRANK), M.D., 

' * Physician to the German Hospital, Philadelphia, late Chief Assist, to Med. Clinic, Jeff. College 

Hospital, etc. 

A HANDBOOK OF THE PRINCIPLES AND PRACTICE OF 

Medicine ; for the use of Students and Practitioners. Based upon Husband's Handbook 
of Practice. In one neat volume, royal 12mo. (Preparing.) 

ABERSHON (S. O.). M.D. 

Senior Physician to and late Lecturer on the Principles and Practice of Medicine at Guy's 
Hospital, etc. 

ON THE DISEASES OF THE ABDOMEN, COMPRISING THOSE 

of the Stomach, and other parts of the Alimentary Canal, Oesophagus, Caecum, Intes- 
tines, and Peritoneum. Second American, from the third enlarged and revised Eng- 
lish edition. With illustrations. In one handsome octavo volume of over 500 pages. 
Cloth, $3 50. (Now Ready.) 



H 



JPOTHERGILL {J. MILNER),M.D. Edin., M.R.C.P. Land., 

*- Asst. Phys. to the West Lond. IIosp. ■;- Asst. Phys. to the City of Lond. Hosp.,etc. 

THE PRACTITIONER'S HANDBOOK OF TREATMENT; Or, tbe 

Principles of Therapeutics. Second edition, revised and enlarged. In one very neat 
octavo volume of about 650 pages. Cloth, $4 00; very handsome half Russia, $5 50. 
(Just Ready:) 
The call for a second edition of Dr. Fothergill's work has been met by the author with a 
revision performed in no perfunctory manner. The entire subject-matter has been submitted 
to a most careful and exhaustive scrutiny, and much new material been added, including articles 
on "The Functional Disturbances of the Liver," "The Means of Acting on the Respiratory 
Nerve Centres," "The Reflex Consequences of Ovarian Irritation," "When Not to Give 
Iron," "Artificial Digestion," etc., thus presenting a complete reflex of the existing condition 
of therapeutical science. 
JDY THE SAME AUTHOR. 

THE ANTAGONISM OF THERAPEUTIC AGENTS, AND WHAT 

IT TEACHES. Being the Fothergillian Prize Essay for 1878. In one neat volume, royal 
12mo. of 156 pages; cloth, $1 00. (Just Ready.) 



Henry C. Lea's Son & Co.'s Publications — {Practice of Medicine). 17 
REYNOLDS {J. RUSSELL). M.D., 

-*- *> Prof, of the Principles and Practice of Medicine in Univ. College, London. 

A SYSTEM OF MEDICINE with Notes and Additions by H^nry Harts- 
horne, M.D., late Professor of Hygiene in the University of Penna. In three large and 
handsome octavo volumes, containing 3052 closely printed double-columned pages, with 
numerous illustrations. Sold only by subscription. Price per vol., in cloth, $5.00: in 
sheep, $6.00 : half Russia, raised bands, $6.50. Per set in cloth, $15 ; sheep, $18 ■ half 
Russia, $19.50 
Volume I. {just ready) contains General Diseases and Diseases of the Nervous System. 
Volume II. (just ready) contains Diseases of Respiratory and Circulatory Systems. 
Volume III. (jtcst ready) contains Diseases of the Digestive and Blood Glandular 
Systems, of the Urinary Organs, of the Female Reproductive System, and of the 
Cutaneous System. 
Reynolds's System of Medicine, recently completed, has acquired, since the first appearance 
of the first volume, the well-deserved reputation of being the work in which modern British 
medicine is presented in its fullest and most practical form. This could scarce be otherwise in 
view of the fact that it is the result of the collaboration of the leading minds of the profession, 
each subject being treated by some gentleman who is regarded as its highest authority — as for 
instance, Diseases of the Bladder by Sir Henry Thompson, Malpositions of the Uterus by 
Graily Hewitt, Insanity by Henry Maudsley, Consumption by J. Hughes Bennet, Dis- 
eases of the Spine by Charges Bland Radcliffe, Pericarditis by Francis Sibson, Alcoholism 
by Francis E. Anstie, Benal Affections by William Roberts, Asthma by Hyde Salter, 
Cerebral Affections by rt Charlton Bastian, Gout and Rheumatism by Alfred Baring Gar- 
rod, Constitutional Syphilis by Jonathan Hutchinson, Diseases of the Stomach by Wilson 
Fox, Diseases of the Skin by Balmanno Squire, Affections of the Larynx by Morell Mac- 
kenzie, Diseases of the Rectum by Blizard Curling, Diabetes by Lauder Brunton, Intes- 
tinal Diseases by John Syer Bristowe, Catalepsy and Somnambulism by Thomas King Cham- 
bers, Apoplexy by J. Hughlings Jackson, Angina Pectoris by Professor Gairdner, Emphy- 
sema of the Lungs by Sir William Jenner, etc. etc. All the leading schools in Great Britain 
have contributed their best men in generous rivalry, to build up this monument of medical sci- 
ence. St. Bartholomew's, Guy's, St Thomas's, University College, St Mary's in London, while 
the Edinburgh, Glasgow, and Manchester schools are equally well represented, the Army Medical 
School at Netley, the military and naval services, and the public health boards. That a work 
conceived in such a spiri% and carried out under such auspices should prove an indispensable 
treasury of facts and experience, suited to the daily wants of the practitioner, was inevitable, and 
the success which it has enjoyed in England, and the reputation which it has acquired on this 
side of the Atlantic, have sealed it with the approbation of the two pre-eminently practical nations. 
Its large size and high price having kept it beyond the reach of many practitioners in this 
country who desire to possess it, a demand has arisen for an edition at a price which shall ren- 
der it accessible to all. To meet this demand the present edition has been undertaken. The 
five volumes and five thousar d pages of the original have by the use of a smaller type and double 
columns, been compres-ed into three volumes of over thre'e thousand pages, clearly and hand- 
somely printed, and offered at a price which renders it one of the cheapest works ever presented 
to the American profession. 

But not only is the American edition more convenient and lower priced than the English; 
it is also better and more complete. Some years having elapsed since the appearance of a 
portion of the work, additions are required to bring up the subjects to the existing condition 
of science. Some diseases, also, which are comparatively unimportant in England, require more 
elaborate treatment to adapt the articles devoted to them to the wants of the American physi- 
cian ; and there are points on which the received practice in this country differs from that 
adopted abroad. The supplying of these deficiencies has been undertaken by Henry Harts - 
horne, M.D., late Professor of Hygiene in the University of Pennsylvania, who has endeavored 
to render the work fully up to the day, and as useful to the American physician as it has proved 
to be to his English brethren. The number of illustrations has also been largely increased, and 
no effort spared to render the typographical execution unexceptionable in every respect. 

Really too much praise can scarcely be given to | house of informat'on, in regard to so many of the 
this noble book. It is a cyclopaedia of medicine 
written by some of the b^st men of Europe. It is 
full of useful information such as one fiuds frequent 
need of in one's daily work ; for no one head can 
possibly carry all the knowledge one needs in gen- 
eral practice, and one runst refer sometimes to one's 
library. As a book of reference it is invaluable. It 
is up with the times. It i's clear and concentrated 
in style, and its form is worthy of its famous pub- 
lisher.— Louisville Med News, Jan. 31, 1S80. 

"Reynolds' System of Medicine" is justly con- 
sidered the most popular work on the principles and 
practice of medicine in the English language The 

contributors to this work are gentlemen of well- I l^ B i g "pkciicaias*pos 8 7bfe7attd-Vh4le These "are 
known reputation on both sides of the Atlantic. ! 8uffic ' ieilt i £ full t0 en F tit i e them to the name of 
Each gentleman has striven . to make his part of the monograpn8t they are not loaded down with such 



subjects with which he should be familiar. — Gail- 
lard's Med. Journ., Feb. 1880. 

There is no medical work which we have in times 
past more frequently and fully consulted when per- 
plexed by doubts as to treatment, or by having un- 
usual or apparently inexplicable symptoms pre- 
sented to us than "Reynolds' System of Medicine." 
Among its contributors are gentlemen who are as 
well known by reputation upon this side of the 
Atlantic as in Great Britain, and whose right to 
speak with authority upon the subjects about 
which they have writteu, is recognized the world 
over. They have evidently striven to make their 



work as practical as pos-ible, and th« information 



unt of detail as to render them wearisome 



contained is such as is needed by the busy practi- ; to the geQeral reader . Iu a word they contain just 
is'™ 61 lS g ' J ° Urn > JaQ - 20 ' j that kind of information which the busy practitioner 

&s | frequently finds himself in need of. In order that 

Dr. Hartshorne has made ample additions and | any deficiencies may be supplied, the publishers 
revisions, all of which give increased value to the have committed the preparation of the book for the 
volume, and render it more useful to the Ameri- I press to Dr. Benry Hartshorne, who^e judicious 
can practitioner. There is no volume in English ! notesdistributed throughout the volnme afford abun- 
medical lite ature more valuable, and every pur- ] dant evidence of the thoroughness of the revision to 
chaser will, on becoming familiar with it, congrat- which he has subjected it. — Am. Jour. Med. Sciences , 
ulate himself on the possession of this vast store- | Jan. 1880. 



18 Henry C. Lea's Son & Co.'s Publications — {Prac of Med., &c). 
J>ARTHOLOW (ROBERTS). A.M., M.D., LL.D. 

**-* Prof, of Materia Medica, and General Therapeutics in the Jeff. Med. Coll. of Phila , etc. 

A PRACTICAL TREATISE ON ELECTRICITY IN ITS APPLI- 
CATION TO MEDICINE. In one very handsome octavo volume of about 450 pages, 
with illustrations. {In press.) 

The constantly increasing therapeutic use of electricity, and the absence of a concise guide 
suited to the wants of the general practitioner, have induced the author to prepare the present 
volume. His object has been to present the most advanced state of existing knowledge in a 
form divested of unnecessary technicalities, keeping constantly in view the practical needs of 
the student and physician. 

As the volume is founded upon a course of lectures delivered in the Jefferson Medical College 
during the spring of 1880, its adaptation to its purpose is insured. Dr. Bartholow's power of lucid 
exposition is well known, and is particularly desirable in a subject such as this, treated from 
the standpoint of the general practitioner and not of the specialist. 

fjlINLAYSON [JAMES], M.D., 

-*■ Physician and Lecturer on Clinical Medicine in the Glasgow Western Infirmary, etc. 

CLINICAL DIAGNOSIS; A Handbook for Students and Prac- 

titioners of Medicine. In one handsome 12mo. volume, of 546 pages, with 85 illustra- 
Cloth, $2 63. (Just Issued.) 

tive from preface to the final page, and ought to be 
gi ven a place on every office table, because it contains 
in a condensed form all that is valuable in semeiology 
and diagnostics to be found in bulkier volumes, and 
because in its arrangement and complete index, it is 
unusually convenient for quick reference in any 
emergency that may come upon the busy practitioner. 
—N. C. Med. Joum., Jan. 1S79. 



tions. Cloth, $2 63 
The book is an excellent one, clear, concise, conve- 



nient, practical. It is replete with the very know- 
ledge the student needs when he quits the lecture- 
room and the laboratory for the ward and sick-room, 
and does not lack in information that will meet the 
wants of experienced and older men.— Phila. Med. 
Times, Jan. 4, 1879. 
This is one of the really useful books. It is attrac- 



TJAM1LTOS (ALLAN McLANE), M.D., 

■*■■*■ Attending Physician at the Hospital for Epileptics and Paralytics. BlackwelV s Island, N. Y., 

and at the Out- Patients' 1 Department of the New York Hospital. 

NERYOUSDISEASES; THEIR DESCRIPTION AND TREATMENT. 

In one handsome octavo volume of 512 pages, with 53 illus. ; cloth, $3 50. (Just Issued.) 
(1HARCOT (J. 3d.). 

\J Professor to the Faculty of Med. Paris, Phys. to La SalpHriere, etc. 

LECTURES ON DISEASES OF THE NERVOUS SYSTEM. Trans- 

lated from the Second Edition by George Sigerson, M.D., M.Ch., Lecturer on Biology, 
etc., Cath. Univ. of Ireland. With illustrations. 1 vol. 8vo. of 288 pages. Cloth, $1 75. 
(Just Ready.) 



CLINICAL OBSERVATIONS ON FUNCTIONAL 
NERVOUS DISORDERS ByC. Handfield Jones. 
M.D., Physician to St. Mary's Hospital, &c. Sec- 



ond American Edition. In onehandsome octavo 
volumeof 348 pages,cloth, $3 25 . 



M 



ORRIS (MALCOLM), M.D., 

Joint Lecturer on Dermatology, St. Mary's Hospital Med. School. 

SKIN DISEASES, Including their Definitions, Symptoms, Diagnosis, 

Prognosis, Morbid Anatomy, and Treatment. A Manual for Students and Practitioners. 

In one 12mo. volume of over 300 pages. With illustrations. Cloth, $1 75. (Now Ready.) 

appliances of cutaneous medicine. He has produced 
a plain, practical book, by aid of which, who so 
chooses may train his eye to the recoguition of 
light but significant differences. The descriptions 
are neither too va*?ue nor over-refined ; the direc- 
tions for treatment are clear and succinct. — London 
Brain, April, 1880. 

The author has handled his subject in a clear and 
concise manner, and as a text-book to students his 
manual will be found useful. — Medical and SurgU 
cat Reporter, March 27, 1880. 

The author's task has been well done and has pro- 
duced one of the best, recent works upon the difficult 
subject of which it treats; there is no work published 
which gives a better view of the elementary facts 
and principles of dermatology. — New Orleans Medi- 
cal and Surgical Journal, April, 188^. 



To physicians who would like to know something 
about skiu diseases, so that when a patient presents 
himself for relief they can make a correct diagnosis 
and prescribe a rational treatment, we unhesitatingly 
recommend this little book of Dr. Morris. The affec- 
tions of the skin are described in a terse, lucid man- 
ner, and their several characteristics so plainly set 
forth that diagnosis will be easy. The treatment 
in each case is such as the experience of the most 
eminent dermatologists advise.— Cincinnati Medi- 
cal News, April, 1880. 



This is emphatically a learner's book ; for we can 
safely say, so far as our judgment goes, that in the 
whole range of medical literature of a like scope, 
there is no book which for clearness of expression, 
and methodical arrangement is better adapted to 
promote a rational conception of dermatology, 



xcellent little book is the first work of a 
squished pupil of Jonathan Hutchinson; it re- 



branch confessedly difficult and perp'exing to the i This 
beginner. — St. Louis Courier of Medicine, April, ^ si 

1880. j commends itself above all by its clearness, method. 

The author of this manual has evidently a full and land precision — PaHs Annates de Dtrmatologie et 
intimate acquaintance with the literature of derma- ■ de Syphiligraphie, 25 April, 1880. 
tology, and with the most recent developments and I 



F 



OX (T2LBURF), MD.,F.R.C.P.,and T. C. FOX, B.A., M.R.C.S., 

Physician to the Department for Skin Diseases, University College Hospital. 

EPITOME OP SKIN DISEASES. WITH FORMULAE. For Stu- 

dents and Practitioners. Second edition, thoroughly revised and greatly enlarged. In 
one very handsome 12mo. volume of 216 pages. Cloth, $1 38. (Just Issued.) 



Henry C. Lea's Son & Co.'s Publications — (Dis.ofthe Chest, &c). 19 
WLINT {AUSTIN), M.D., 

Professor of the Principles and Practice of Medicine in Bellevue Hospital Med. College, N. T. 

A MANUAL OF PERCUSSION AND AUSCULTATION; of the 

Physical Diagnosis of Diseases of the Lungs and Heart, and of Thoracic Aneurism. 

Second edition. In one handsome royal 12mo. volume : cloth, $1 63. (Just Ready.) 
Prof. Flint is so well known as a medical teacher , physician's library. —Med. and Surg. Reporter, 
and writer that it seems superfluous to state that j March IS 1S80. 

th* subject has been treated in a thorough and sys- The mtle work before us has already become a 
tematic manner. In revising it for a second edition gta ndard one. and has become extensively adopted 
the author has confined himself to such additions as a8 a tex t-book. Th*re is certainly none better. It 
seem likely to render it more useful, not only to ( con r a ins the substance of the lessons which the 
students engaged in the practical study of the sub- ; author has for m , ny year „ given, in connection with 
ject, but also to practitioners as a hand book for l practical i DStruc tion in auscultation and percussion, 
ready reference, and we do not hesitate in saying t t0 private classes, composed of medical stodentsand 
that it would prove a valuable addition to every | p act itioners.— Cincinnati Med. News, Feb. 1S80. 



OF THE SAME AUTHOR. 

PHTHISIS: ITS MORBID ANATOMY, ETIOLOGY, SYMPTOM- 
ATIC EVENTS AND COiMPLICATIONS, FATALITY AND PROGNOSIS, TREAT- 
MENT, AND PHYSICAL DIAGNOSIS ; in a series of Clinical Studies. By Austin 
Flint, M D. , Prof, of the Principles and Practice of Medicine in Bellevue Hospital Med. 
College, New York. In one handsome octavo volume: $3 50. (Lately Issued.) 



T>Y THE SAME AUTHOR. 

A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, 

AND TREATMENT OF DISEASES OF THE HEART. Second revised and enlarged 

edition. In one octavo volume of 550 pages, with a plate, cloth, $4. 

Dr. Flint chose a difficult subject for his researches, | and clearest practical treatiseon those subjects, and 

and has shown remarkable powers of observation ] should be in the hands of all practitioners and stu- 

and reflection, as well as greatindustry, in his treat- lent6. It is a credit to American medical literature. 

ment of it. His book must be considered the fullest I —Amer. Journ. of the Med. Sciences, July, 1860. 

D7 THE SAME AUTHOR. 

A PRACTICAL TREATISE ON THE PHYSICAL EXPLORA- 
TION OF THE CHEST AND THE DIAGNOSIS OF DISEASES AFFECTING THE 
RESPIRATORY ORGANS. Second and revised edition. In one handsome octavo volume 
of 595 pages, cloth, $4 50. 



B 



ROWN {LENNOX), F.R.G.S. Ed., 

Senior Surgeon to the Central London Throat and Ear Hospital, etc. 

THE THROAT AND ITS DISEASES. With one hundred Typical 

Illustrations in colors, and fifty wood engravings, designed and executed by the author. 
In one very handsome imperial octavo volume of 351 pages ; cloth, $5 00. (Just Ready.) 



CfElLER (CARL), M.D., 

Av3 Lecturer on Laryngoscopy at the Univ. of Penna., Chief of the Throat Dispensary at the 

Univ. Hospital, Phila., etc. 

HANDBOOK OF DIAGNOSIS AND TREATMENT OF DISEASES OF 

THE THROAT AND NASAL CAVITIES. In one handsome royal 12mo. volume, 
of 156 pages, with 35 illustrations; cloth, $1. (Just Ready.) 

We most heartily commend this book as showing A convenient little handbook, clear, concise, and 
sound judgment in practice, and perfect familiarity j accurate in its method, and admirably fulfilling its 
with the literature of the spec alty it so ably epi- purpose of bringing the subject of which it treats 
tomizes. — Philada. Med. Times, July 5, 1S79. within the comprehension of the general practi- 

I tioner.— N. C. Med. Jour., June, 1S79. 



WILLIAMS'S PULMONARY CONSUMPTION; its 
Nature, Varieties, and Treatment. With an An- 
alysis of One Thousand Cases to exemplify its 
duration. In one neat octavo volume of about 
350 pages ; cloth, $2 50. 

SLADE ON DIPHTHERIA; its Nature and Treat- 
ment, with an Account of the History of its Pre- 
valence in various Countries. Second and revised I 
edition. In one neatroval 12mo. volume, cloth,! 
$1 25. 

WALSHEON THE DISEASESOF THEHEART AND | 
GREAT VESSELS. Third American Edition. In 
1 vol. 8vo., 420 pp., cloth, $3 00. 

CHAMBERS'S MANUAL OF DIET AND REGIMEN 
IN HEALTH AND SICKNESS. In one handsome I 
octavo volume. Cloth, $2 75. 

LA ROCHE ON PNEUMONIA. 1 vol. 8vo., cloth, 
of 500 pages Price, $3 00. 

WILSON'S STUDENT'S BOOK OV CUTANEOUS j 
MEDICINE and Diseases of the Skin. In one ! 
vtsry handsome royal 12mo volume. $3 50. 



FULLER ON DISEASES OF THE LUNGS AND AIR- 
PASSAGES. Their Pathology, Physical Diagnosis, 
Symptoms, and Treatment. From the second and 
revised English edition. In one handsome ocatvo 
volume of about 500 pages : cloth, $3 50. 

SMITH ON CONSUMPTION ; ITS EARLY AND RE- 
MEDIABLE STAGES. 1 vol.8vo.,pp.254. *2 25. 

BASHAM ON RENAL DISEASES : a Clinical Guide 
to their Diagnosis and Treatment. With Illustra- 
tions. In one 12mo. vol. of 304 pages, cloth, $2 00. 

LECTURES ON THE STUDY OF FEVER. By A. 
Hudson, M.D., M.R.I. A., Physician to the Meath 
Hospital. In one vol. 8vo., cloth, $2 50. 

A TREATISE ON FEVER. By Robert D. Lyons, 
K.C C. Inone octavo volume of 362 pages, clotb 
*2 25 

HILLIER'S HANDBOOK OF SKIN DISEASES, for 
Students and Practitioners. Second Am Ed. In 
oue roval 12mo. vol. of 358 pp. With illustrations. 
Cloth, $2 25. 



20 Henry C. Lea's Son & Co.'s Publications — (Venereal Diseases, &c). 



RUMSTEAD {FREEMAN J.), M.D.,LL.D., 

•*-* Professor of Venerea] Diseases at the Col. of Phys. and Surg., New York, &c . 

THE PATHOLOGY AND TREATMENT OF VENEREAL DIS- 

EASES. Including the results of recent investigations upon the subject. Fourth edition, 
revised and largely rewritten with the co-operation of R. W. Taylor, M.D., of New 
York, Prof, of Dermatology in the Univ. of Vt. En one large and handsome octavo 
volume of 835 pages, with 138 illustrations. Cloth, $4 75 ; leather, $5 75; half Russia, 
$6 25. (Just Ready.) 
This work, on its first- appearance, immediately took the position of a standard authority on 
its subject wherever the language is spoken, and the success of an Italian translation shows 
that it is regarded with equal favor on the Continent of Europe. In repeated editions the author 
labored sedulously to render it more worthy of its reputation, and in the present revision no 
pains have been spared to perfect it as far as possible. Several years having elapsed since 
the publication of the th-rd edition, much material has been accumulated during the interval 
by the industry of syphilolog^ts, and new views have been enunciated. All this so far as 
confirmed by observation and experience, has been incorporated ; many portions of the volume 
been rewritten, the series of illustrations has been enlarged and improved, and the whole may 
be regarded rather as a new work than as a new edition. It is confidently presented as fully on 
a level with the most advanced condition of syphilology, and as a work to which the practi- 
tioner may refer with the certainty of finding clearly and succinctly set forth whatever falls 
within the scope of such a treatise. 

"We have to congratulate our countrymen upon 
the truly valaable addition which they have made 
to American literature. The careful estimate of the 
value of the volume, which we have made, justifies 
us in declaring that this is the best treatise on 
venereal diseases in the English langaage, and, we 
might add, if there is a better in any other tongue 
we cannot name it ; there are certainly no books in 
which the student or the general practitioner can 
find such an excellent resume" of the literature of 
any topic, and such practical suggestions regarding 
the treatment of the various complications of every 
venereal disease. We take pleasure in repeating 
that we believe this to be the best treatise on vene- 
real disease in the English language, and we con- 
gratulate the authors upon their brilliant addition 
to American medical literature. — Chicago Med. Jour- 
nal and Examiner, February, 1880. 

It is, without exception, the most valuable single 
work on all branches of the subject of which it treats 
in any language. The pathology is sound, the work 
is, at the same time, in the highest degree practical, 
and the hints that he will get from it for the man- 
agement of any one case, at all obscure or obstinate, 



will more than repay him for the outlay. — Archives 
of Medicine, April, 1880. 

This now classical work on venereal disease comes 
to us in its fourth edition rewritten, enlarged, and 
materially improved in every way. Dr. Taylor, as 
we had everv reason to exuect, has performed this 
part of his work with unusual excellence. We feel 
that what has been written has done but scanty jus- 
tice to the merits of this truly great treatise. — St. 
Louis Courier of Medicine, Feb. 1880 

We find that we have here practically a new book 
—that the statement of the title-page, as to the fact 
that it has been largely rewritten, is a sufficiently 
modest announcement for th* important changes in 
the text. After a thorough examination of the pre- 
sent edition, we can assert confidently that the euor- 
mous labor we have described has been here most 
faithfully and conscientiously performed. — Araer. 
Joum. Med. Sci., Jan. 1880. 

It is one of the best general treatises on venereal 
diseases with which we are acquainted, and is espe- 
cially to be recommended as a guide to the treatment 
of syphilis. — London Practitioner, March, 1880. 



c 



ULLERIER {A.), and 

Surgeon to the Hdpital du Midi. 



JDUMSTEAD {FREEMAN J.), 

•*-* Professor of Venereal Diseases in the. College of 
Physicians and Surgeons, N. Y. 



AN ATLAS OF VENEREAL DISEASES. Translated and Edited by 

Freeman J. Bumstead. In one large imperial 4to. volume of 328 pages, double-columns, 
with 26 plates, containing about 150 figures, beautifully colored, many of them the size of 
life; strongly bound in cloth, $17 00 ; also, in five parts, stout wrappers, at $3 per part. 
Anticipating a very large sale for this work, it is offered at the very low price of Three Dol- 
lars a Part, thus placing it within the reach of all who are interested in this department of 
practice. Gentlemen desiring early impressions of the plates would do well to order it without 
delay. A specimen of the plates and text sent free by mail, on receipt of 25 cents. 



LEE'S LECTURES ON SYPHILIS AND SOME 
FORMS OF LOCAL DISEASE AFFECTING PRIN- 
CIPALLY THE ORGANS OF GENERATION. In 
one handsome octavo volume; cloth, $2 25. 



HILL ON SYPHILIS AND LOCAL CONTAGIOUS 
DISORDERS. In one handsome octavo volume 
cloth $3 25. 



1/TTEST {CHARLES), M.B., 

Phvsician to the Hospital for Sick Children, London, Ac. 

LECTURES ON THE DISEASES OP INFANCY AND CHILD- 
HOOD. Fifth American from the sixth revised and enlarged English edition. In one large 
and handsome octavo volume of 678 pages. Cloth, $4 50; leather, $5 50. (Lately Issued.) 



T>Y THE SAME AUTHOR. (Lately Issued.) 

ON SOME DISORDERS OF THE NERVOUS SYSTEM IN CHILD- 
HOOD; being the Lumleian Lectures delivered at the Royal College of Physicians of 
London, in March, 1871. In one volume small 12mo., cloth, $1 00. 



JDY THE SAVE AUTHOR. 

LECTURES ON THE DISEASES OF WOMEN. Third American, 

from the Third London edition. In one neat octavo volume of about 550 pages, cloth 
$3 75; leather, $4 75. 



Henry C. Lea's Son & Co.'s Publications — (Dis. of Children, &c). 21 



VMITH{J. LEWIS), M.D., 

Clinical Professor of Diseases of Children in the Bellevue Hospital Med. College, N T. 

A COMPLETE PRACTICAL TREATISE ON THE DISEASES OF 

CHILDREN. Fourth Edition, revised and enlarged. In one handsome octavo volume 
of about 750 pages, with illustrations. Cloth, $4 50 ; leather, $5 50 ; half Russia, $6. 
(JSow Ready.) 
The very marked favor with which this work has been received wherever the English lan- 
guage is spoken, has stimulated the author, in the preparation of the Fourth Edition, to spare 
no pains in the endeavor to render it worthy in every respect of a continuance cf professional 
confidence. Many portions of the volume have been rewritten, and much new matter intro- 
duced, but by an earnest effort at condensation, the size of the work has not been materially 
increased. 



In the period -which has elapsed since the third 
edition of the work, so extensive have heen the ad- 
vances that whole chapters required to be rewiitten, j 
and hardly a page could pass without some material i 
correction or addition. This labor bas occupied the 
writer closely, and he has performed it conscien- I 
tiously, so that the book may be considered a faith- j 
ful portraiture of an exceptionally wide clinical j 
experience in infantile diseases, corrected by a care- | 
ful study of the recent literature of the subject. — 
Med. and Surg. Reporter, April 5, 1879. 

It is scarcely necessary for us to say the work be- ; 
fore us is a standard work upon diseases of children, 
and that do work has a higher standing than it upon j 



This excellent work is so well known that an 
ex ended notice at this time would be superfluous. 
The author has taken advantage of the demand for 
another new eHit on to revise in a most careful 
manner the entire book ; and the numerous correc- 
tions and additions evince a determination on his 
part to keep fally abreast with the rapid progress 
that is being made in the knowledge and treatment 
of children's diseases. By the adoption of a some- 
what closer type, an increase in size of only thirty 
paares has been necessitated by the new subject 
matter introduced.— Boston Med. and Surg. Jour., 
May 29, 1879. 

Probably no other work ever published in this 



those affections. In consequence of its thorough re- i country upon a medical subject has reached such a 
vision, the work has been made of more value than j heighth of popularity as has this well-known trea- 
ever, and may be regarded as fully abreast of the i tise. As a text and reference-book it is pre-emi- 
times. We cordially commend it to students and j nently the authority upon diseases of children. It 
physicians. There is no better work in the language | stands deservedly higher in the estimation of the 



on diseases of children. — Cincinnati Med. News, 
March, 1879. 

The author has evidently determined that it shall 
not lose ground in the esteem of the profession for 
want of the latest knowledge on that important 
department of medicine. He bas accordingly in- 
corporated in the present edition the useful and 
practical remits of the latest study aDd experience, 
both American aDd foreign, especially those bearing 
on therapeutics. Altogether the book has been 
greatly improved, while it has not been greatly 
increased in size. — Sew York Mtdieal Journal, 
June, 1S79. 



profession than any other work upon the same sub- 
ject.— Nashville Journ. of Med. and Surg., May, 
1879. 

The author of this work has acquired an immense 
experience as physician to three of the large char- 
ities of New York in which children are treated. 
These asylums afford unsurpassed opportunities for 
observing the effects of different plans of treatment, 
and the results as emb >died in this volume may be 
accepted with faith, and should be in the possession 
of all practitioners now. in vi^w of the approaching 
season when the diseases of children always increase. 
—Nat Med. Review, April, 1879. 



£ WAYNE {JOSEPH GRIFFITHS), M.I)., 

Physician-Accoucheur to the British General Hospital, &c. 

OBSTETRIC APHORISMS FOR THE USE OF STUDENTS COM- 

MENCING MIDWIFERY PRACTICE Second American, from the Fifth and Revised 
London Edition with Additions by E. R. Htjtchins, M.D. With Illustrations. In one 
neat 12mo volume. Cloth, $] 25. (Lately Issued.) 
*0* See p. 3 of this Catalogue for the terms on which this work is offered as a premium to 
subscribers to the "American Journal of the Medical Sciences." 



CHURCHILL ON THE PUERPERAL FEVER AND 
OTHER DISEASES PECULIAR TO WOMEN. 1 vol. 
8vo. , pp. 4:50, cloth $2 50. 

DE WEES'S TREATISE ON THE DISEASES OF FE- 
MALES. With illustrations. Eleventh Edition . 
with the Author's lastimpro ^ementsand correc- 
tions. In one octavo volume of 536 pages, with 
plates, cloth. $3 00. 



MEIGS ON THE NATURE, SIGNS, AND TREAT- 
MENT OF CHILDBED FEVER. 1 vol. Svo., pp. 
365. cloth. $2 00. 

ASHWELL'S PRACTICAL TREATISE ONTHE DIS- 
EASES PECULIAR TO WOMEN. Third American, 
from the Third and revised London edition. 1 vol. 
8vo., pp. 528, cloth. $3 50. 



H 



ODGE {HUGH L.), M.D. , 

Emeritus Professor of Obstetrics, &c, in the University of Pennsylvania. 

ON DISEASES PECULIAR TO WOMEN ; including Displacements 

of the Uterus. With original illustrations. Second edition, revised and enlarged. In 
one beautifully printed octavo volume of 531 pages, cloth, $4 50. 



SJHURCHILL {FLEETWOOD), M.D., M.R.I.A. 

ON THE THEORY AND PRACTICE OF MIDWIFERY. Anew 

American from the fourth revised and enlarged London edition. With notes and additions 
by D. Francis Condie, M.D., author of a "Practical Treatise on the Diseases of Chil- 
dren," <fec. With one hundred and ninety four illustrations. In one very handsome octavo 
volume of nearly 700 large pages. Cloth, $4 00; leather, $5 00. 



MONTGOMERY'S EXPOSITION OF THE SIGNS 
AND SYMPTOMS OF PREGNANCY. With two 
exquisitecolored plates, and numerous wood-cuts. 
Tn 1 t-aLSt-o. ofnearlvfiOOT)p..cloth,$3 75. 

CONDIE'S PRACTICAL TREATISE ON THE DIS- 
EASES OF CHILDREN. Sixth edition, revised 
and augmented. In one large octavo volume of 
nearly 8 r closely-printed pages, cloth, $5 25 ; 
leather $6 25. 



RIGBY'S SYSTEM OF MIDWIFERY. With notes 
and Additional Illustrations. Second Ameriian 
edition. One volume octavo, cloth 422 pages, 
*2 50. 

SMITH'S PRACTICAL TREATISE ON THE WAST- 
ING DISEASES OF INFANCY AND CHiLDHoOD. 
Second American, from the second revised and 
enlarged Eaclish edition. In one handsome octa- 
vo voiame, cloth, $2 50. 



Henry C. Lea's Son & Co.'s Publications — (Dis. of Women). 



fHOMAS {T.GAILLARD),M.D., 
Professor of Obstetrics, &c, in the College of Physicians and Surgeons, N. Y., Ac 

A PRACTICAL TREATISE ON THE DISEASES OF WOMEN. Fifth 

edition, thoroughly revised and rewritten. In one large and handsome octavo volume 

of over 850 pages, with about 270 illustrations. (In Press.) 
The author has taken advantage of the opportunity afforded by the call for a new edition of 
this work to render it worlhy a continuance of the very remarkable favor with which it has 
been received. Every portion of the work has been carefully revised, very much of it has 
been rewritten, and additions and alterations introduced wherever the advance of science and 
the increased experience of the author have shown them desirable. At the same time special 
care has been exercised to avoid undue increase in the size of the volume. To accommodate 
the numerous additions a more condensed but v ry clear letter has been used, notwithstanding 
which, the number of pages has been increased by more than fifty. The series of illustrations 
has been extensively changed ; many which seemed to be superfluous have been omitted, and a 
large number of new a^d superior drawings have been inserted. In its improved form, there- 
fore, it is hoped that the volume will maintain the character it has acquired of a standard 
authority on every detail of its important subject. 
A few notices of the previous edition are appended. 
A work which has reached a fourth edition, and 
that, too. in the short space of five years, has achieved 
a reputatiou which places it almost beyond the reach 
of criticism, and the favorable opinions which we have 
already expressed of the former editions seem to re- 
quire that we should do little more than announce 
this new issue. We cannot refrain from saying that, 
as a practical work, this is second to none in the Eng- 
lish, or. indeed, in any other language. The arrange- 
ment of the contents, the admirably clear manner in 
which the subject of the differential diagnosis of 
several of the diseases is handled, leave nothing to be 
desired by the practitioner who wants a thoroughly 
clinical work, one to which he can refer in difficult 
eases of doubtful diagnosis with the certainty of gain- 



ing light and instruction. Dr. Thomas is a man with a 
pery clear head and decided views, and there seems to 
be nothing which he so much dislikes a.«hazy notions 
)f diagnosis and blind routiue and unreasonable thera- 
peutics. The student who will thoroughly study this 
book and test its principles by clinical observation, will 
certainly not be guilty of these faults. — London Lancet, 
Feb. 13, 1875 

Reluctantly we are obliged to close this unsatis- 
factory noticeof so excellent a work, and in conclu- 
sion would remark that, as a teacher ofgynaecology. 
both didactic and clinical, Prof. Thomas has certainly 
taken the lead far ahead of his confreres, and as an 
author he certainly has met with unusual and mer- 
ited success. — Am. Journ. of Obstetrics, Nov. 1874. 



JDARNES (ROBERT), M.D., F.R.C.P., 

•*-* Obstetric Physician to St. Thomas's Hospital, &c. 

A CLINICAL EXPOSITION OF THE MEDICAL AND SURGI- 
CAL diseases OF WOMEN. Second American, from the Second Enlarged and Revised 
English Edition. In one handsome* oc.tavq volume, of 784 pages, with 181 illustrations. 
Cloth, $4 50 ; leather, $5 50 ; half Russia, $6. (Just Ready.) 
The call for a new edition of Dr. Barnes's work on the Diseases of Females has encouraged 
the author to make it even more worthy of the favor of the profession than before. By a rear- 
rangement and careful pruning space has been found for a new chapter on the Gynaecological 
Relations of the Bladder and Bowel Disorders, without increasing the size of the book, while 
many new illustrations have been introduced where experience has shown them to be needed. It 
is therefore hoped that the volume will be found to reflect thoroughly and accurately the present 
condition of gynaecological science. 

Dr Barnes stands at the head of his profession in the work is a valuable one, and should be largely 



the old country, and it requires but scant scrutiny 
of his book to show that it has been sketched by a 
master. It is plain, practical common sense ; shows 
very deep research without being pedantic; is emi- 
nently calculated to inspire enthusiasm without in- 
culcating rashness; points out the dangers to be 
avoided as well as the success to be achieved in the 
various operations connected with this branch of 
medicine; and will do much to smooth the rugged 
path of the young gynaecologist and relieve the per- 
plexity of the man of mature years. — Canadian 
Journ. of Med. Science, Nov. 1878. 

We pity the doctor who, having any consider- 
able practice in diseases of women, has no copy of" 
" Barnes" for daily consultation and instruction. It 
is at once a book of great learning, research, and 
individual experience, and at the same time emi- 
nently practical. That it has been appreciated by 
the profession, both in Great Britain and in this 
country, is shown by the second edition following 
so soon upon the first. — Am. Practitioner, Nov. 
1878. 

Dr. Barnes's work is one of a practical character, 
largely illustrated from cases in his own experience, 
bnt by no means confined to such, as will be learned 
from the fact that he quotes from no less than 628 

medical authors in numerous countries. Coming | students and practitioners. — N. C. Med. Journ. 
from such an author, it is not necessary to say that | Oct. 1878 



consulted by the profession.— Am. Svpp Obstetrical 
Journ. Gt. Britain and Ireland, Oct. 1S78. 

No other gynaecological work holds a higher posi- 
tion, having become an authority everywhere in 
diseases of women. The work has been brought 
fully abreast of present knowledge. Every practi- 
tioner of medicine should have it upon the shelves 
of his library, and the student will find it a superior 
text-book. — Cincinnati Med. News, Oct. 1S78. 

This second revised edition, of course, deserves all 
the commendation given to its predecessor, with the 
additional one that it appears to include all or nearly 
all the additions to our knowledge of its subject that 
have been made since the appearance of the first edi- 
tion The American references are, for an English 
work, especially full and appreciative, and we can 
cordially recommend the volume to American read- 
ers — Journ. of Nervous and Mental Disease, Oct. 
1878. 

This second edition of Dr. Barnes's great work 
comes to us containing many additions and improve- 
ments which bring it up to date in every feature. 
The excellences of the work are too well known to 
require enumeration, and we hazard the prophecy 
that they will for many years maintain its high po- 
sition as a standard text book and guide book for 



a 



HAD WICK [JAMES R.), A.M., M.D. 

A MANUAL OF THE DISEASES PECULIAR TO WOMEN. 

neat volume, royal 12mo., with illustrations. (Preparing.) 



Ill 



one 



Henry C. Lea's Son & Co.'s Publications — (Dis.of Women), 



23 



T?MMET {THOMAS ADDIS). M.D. 

**-* Surgeon to the Woman's Hospital, New York, etc. 

THE PRINCIPLES AND PRACTICE OF GYNAECOLOGY, for the 

use of Students and Practitioners of Medicine. Second Edition. Thorouglv Revised. 
In one large and very handsome octavo volume of 875 pages, with 133 illustrations. 
Cloth, $5; leather, $6 ; half Russia, $6 50. {Just Ready.) 

Preface to the Second Edition. 

The unusually rapid exhaustion of a large edition of this work, while flattering to the author 
as an evidence that his labors have proved acceptable, has in a great measure heightened his 
sense of responsibility. He has therefore endeavored to take full advantage of the opportunity 
afforded to bim for its revision. Every page has received his earnest scrutiny; the criticisms 
of his reviewers have been carefu^y weighed ; and while no marked increase has been made in 
the size of the volume, several portions have r een rewritten, and much new matter has been 
added. In this minute and thorough revision, the labor involved has been much greater than 
is perhaps apparent in the results, but it has been cheerfully expended in the hope of rendering 
the work more worthy of the favor which has been accorded to it by the profession. 

In no country of the world has gynaecology re- 1 not careless reading but profound study. Its value 



ceived moreatt^ntion th^nin Amerca. It is, then, 
with a feeling of pleasure that we. welcome a work 
on diseases of women from so eminent a gynsecolo 
gist as Dr. Emmet, and the work is essentially clini- 
cal, and leaves a strong impress of the author's in- 
dividuality. To criticize, with lhe care it merit-, 
the book throughout, would dem-ind far more spacp 
than is at our command. In paning, we can say 
that the work teems with original ideas, fresh and 
valuable methods of practice, and is written in a 
clear and elegant style, worthy of the literary repu- 
tation of the country of Longfellow and Oliver Wen- 
dell Holmes.— Brit. Med. Journ , Feb. 21, 18S0. 

No gyn ecological treatise has appeared which 
contains an equal amount of original and useful 
matter; nor does the medical and surgical history 
of America include a hook mor« novel and useful. 
The tabular and statistical information which it 
contains is marvellous, both in quantity and accu- 
racy, and cannot be otherwise tbaD invaluable to 
future investigators. It is a work which demands 



a contribution '0 gynaecology is, perhaps, greater 
than that of all previous literature on the subject 
combined. — Chicago Med Gaz., April 6, 1S80 

The wide reputation of tbe author makes its pub- 
lication an event in the gynaecological world ; and 
a glance through its pages shows that it is a work 
to be studied with care. . . . It must always be a 
work to be carefully studied and frequently con- 
sulted by those who practise this branch of our pro- 
fession.— Lond. Med. Titans and Gaz , Jan. 10, 18>0. 

The character of the work is too well known to 
require extended notice — snffire it to say that no 
recent work upon any subject has attained such 
great popularity i-o rapidly As a work of general 
reference upon the subject of Diseases of Women ir 
^s invaluable. As a record of the largest clinical 
experience and observation it has no equal. No 
physician who pretends to keep up with the ad- 
vances of this department of medicine can afford to 
be without it. — Nashville Journ. of Medicine and 
Surgery, May, 1F80. 



D 



UNCAN {J. MATTHEWS), M.I)., LL.D., F.R.S.E., etc. 

CLINICAL LECTURES ON THE DISEASES OF WOMEN, 

Delivered in Saint Bartholomew's Hospital. In one very neat octavo volume of 173 

pages. Cloth, $1 50. (Just Ready.) 

The author is a remarkably clear lecturer, and 
his discussion of symptoms and treatment is full 
and suggestive. It will be a work which will not 
fail to be read with benefit by practitioner- as well 
as by students. — Phila. Med. and Surg. Reporter, 
Feb. 7,1880. 

We have read this book with a ?reat deal of 
pleasure. It is full of good things. The hints ou 
pathology and treatment scattered through the book 



They are in every way worthy of their author ; 
indeed, we look upon them as among the most valu- 
able of his contributions They are all up >n mat- 
ters of great interest to the general practitioner 
Some of th^m deal wi:h subjects that are not, as a 
rule, adequately handled in the text-books ; others 
of them, while bearing upon topics that are usually 
treated of at length in such works, yet bear such a 
stamp of individuality that, if widely read, as they 



certainly deserve to be, they cannot fail to exert a ; are souad trustworthy, and of great value. A 
wholesome restraint upon the undue eagerness with , nea lthy scepticism, a large experience, and a clear 
whichmany young phys.cia.ns seem bent upon fol-j udat are everywhere manifest. Instead of 
lowing the wild teachings which so infest the gynae- | Drist]ing with ad7ice f doubtful value and un- 

i sound character, the book is in every respect a safe 
I guide.— The London Lancet, Jan. 21, 1880. 



cology of the present day. 
March, 1SS0 



■N. T. Med. Journ. 



TfAMSBOTHAM {FRANCIS H.), M.D. 

THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDI- 
CINE AND SURGERY, in reference to the Process of Parturition. A new and enlarged 
edition, thoroughly revised by the author. With additions by W. V. Keating, M. D., 
Professor of Obstetrics, <fcc, in the Jefferson Medical College, Philadelphia. In one birsre 
and handsome imperial octavo volume of 650 pages, strongly bound in leather, with raised 
bands ; with sixty-four beautiful plates, and numerous wood-cuts in the text, containing in 
all nearly 200 large and beautiful figures. $7 00. 



TU'INCKEL (F.), 

• * * Professor and Director of the Gynaecological Clinic in the University of Rostock. 

A COMPLETE TREATISE ON THE PATHOLOGY AND TREAT- 
MENT OP CHILDBED, for Students and Practitioners. Translated, with the consent 
of the author, from the Second German Edition, by James Rkad Chadwick, M.D. In 
one octavo volume. Cloth, $4 00. (Lately Issued.) 

/TANNER {THOMAS H.), M.D. 

ON THE SIGNS AND DISEASES OF PREGNANCY. First American 

from the Second and Enlarged English Edition. With four colored plates and illustra- 
tions on wood. In one handsome octavo volume of about 500 pages, cloth, $4 25. 



24 Henry C. Lea's Son & Co.'s Publications — {Midwifery). 



P 



LAYFAIR ( W. S.\, M.D., F.R.C.P., 

Professor of Obstetric Medicine in King's College, etc. etc. 

A TREATISE ON THE SCIENCE AND PRACTICE OF MIDWIFERY. 

Third American edition, revised by the author. Edited, with additions, by Robert P. 
Harris, M.D. In one handsome octavo volume of about 700 pages, with nearly 2C0 
illustrations. Cloth, $4; leather, $5; half Russia, $5 50. (Just Ready .) 

EXTRACT FROM THE AUTHOR'S PREFACE. 

The second American edition of my work on Midwifery being exhausted before the corre- 
sponding English edition, I cannot better show my appreciation of the kind reception my book 
has received in the United States than by acceding to the publisher's request that I should 
myself undertake the issue of a third edition. As little more than a year has elapsed since 
the second edition was issued, there are naturally not many changes to make, but I have, 
nevertheless, subjected the entire work to careful revision, and introduced into it a notice of 
most of the more important recent additions to obstetric science. To the operation of gastro- 
elytrotomy — formerly described along with the Caesarean section — I have now devoted a sepa- 
rate chapter. The editor of the Second American edition, Dr. Harris, enriched it with many 
valuable notes, of which, it will be observed, I have freely availed myself. 

The medical profession has now the opportunity 
of adding to their stock of standard medica) works 
one of the best volumes on midwifery ever published. 
The subject is taken up with a master hand. The 
part devoted to labor in all its various presentations, 
the management and results, is admirably arranged, 
and the views entertained will be found essentially 
modern, and the opinions expressed trustworthy 
The work abounds with plates, illustrating various 
obstetrical positions; they are admirably wrought, 
and afford great assistance to the student. — N. 0. 
Med. and Surg. Journ., March, 1880. 

If inquired of by a medical student what work on 
obstetrics we should recommend for him, as par 
excellence, we would undoubtedly advise him to 
choose Playfair'3. It is of convenient size, but what 
is of chief importance, its treatment of the various 
subjects is concise and plain. While the discussions 
and descriptions are sufficiently elaborate to render 



a very intelligent idea of them, yet all details not 
necessary for i full understanding of the subject are 
omitted. — Cincinnati Med. News, Jan. 1880. 

The rapidity with which one edition of this work 
follows another is proof alike of its excellence and 
of the estimate that the profession has formed of it. 
It is indeed so well known and so highly valued 
that nothing need be said of it as a whole. All 
things considered, we regard this treatise as the very 
best on Midwifery in the English language. —N. Y. 
Medical Journal, May, 1880 

It certainly is an admirable exposition of the 
Science and Practice of Midwifery. Of course the 
additions made by the American editor, Dr. K. P. 
Harris, who never utters an idle word, and whose 
studious researches in some special departments of 
obstetrics are so well known to the profession, are 
of great value —The American Practitioner, April, 
1880. 



RARNES {FANGOURT), M.D., 

-*-* Physician to the General Lying-in Hospital, London. 

A MANUAL OF MIDWIFERY FOR MIDWIVES AND MEDICAL 

STUDENTS. With 50 illustrations. In one neat royal 12mo. volume of 200 pages; 

cloth, $1 25. {.Now Ready.) 

will be popular with those for whom it has been 
prepared. The exam ning questions at the back 
will be found very useful. — Cincinnati Med. News, 



The book is written in plain, and as far as pos- 
sible in untechnical language. Any intelligent mid- 
wife or medical student can easily comprehend the 
directions. It will undoubtedly fill a want, and 



Aug. 1879. 



rpEE OBSTETRICAL JOURNAL. [Free of postage for W§0.) 

THE OBSTETRICAL JOURNAL of Great Britain and Ireland: 

Including Midwifery, and the Diseases of Women and Infants. A monthly of 
64 octavo pages, very handsomely printed. Subscription, Three Dollars per annum 
Single Numbers, 25 cents each. 
With the January number will terminate Vol. VII. of the Obstetrical Journal. The first 
No. of Vol. VIII. will be issued about Feb. 1st; the "American Supplement" of 16 pages 
per No. will be discontinued, and the periodical will thenceforth consist of 64 pages per number, 
at the exceedingly low price of Three Dollies per annum, free of postage. For this trifling 
turn the subscriber will thus obtain more than 750 pages per annum, cont ining an extent and 
variety of information which may be estimated from the fact that Vol. VI. of the "Obstetri- 
cal Journal" contains in 
Original Communications 
Hospital Practice .... 
General Correspondence . . 

Reviews of Books 

Proceedings of Societies . . 
In Monthly Summary, Obstetric 
and that it numbers among its contributors the distinguished names of Lhibe Atthill, J. H. 
Aveling, Robert Barnes, J. Henry Bennet, Nathan Bozeman, Thomas Chambers, Fleet-^ 
wood Churchill, Charles Clay, John Clay, J. Matthews Duncan, Arthur Farre, Robert 
Greenhalgh, W. M. Graily Hewitt, J. Braxton Hicks, William Leishman, Angus Mac- 
donald, Alfred Meadows, Alex. Simpson, J. G. Swayne, Lawson Tait, Edward J. Tilt, 
E. H. Trenholme, T. Spencer Wells, Arthur Wigglesworth, and many other distin- 
guished practitioners. Under such auspices it has amply fulfilled its object of presenting to 
the physician all that is new and interesting in the rapid development of obstetrical and gynae- 
cological science. 

As a very large increase in the subscription list is anticipated under this reduction in price, 
gentlemen who propose to subscribe, and subscribers intending to renew their subscriptions, 
are recommended to lose no time in making their remittances, as the limited number printed 
may at any time be exhausted. 



44 Articles 

4 " 

5 " 
9 " 


In Monthly Summary, Gynrcic 28 Articles 

" " Pediatric 4 " 
News 9 " 


101 " 

73 " 


241 



Henry C. Lea's Son & Co.'s Publications — (Midwifery , Surgery). 25 



TEISHMAN (WILLIAM), M.D., 

"^ Regius Professor of Midwifery in the. University of Glasgow, &c. 

A SYSTEM OF MIDWIFERY, INCLUDING THE DISEASES OF 

PREGNANCY AND THE PUERPERAL STATE. Third American edition, revieed by 
the Author, with additions by John S. Parry, M.D., Obstetrician to the Philadelphia 
Hospital, &o. In one large and very handsome octavo volume, of 733 pages, with over 
two hundred illustrations. Cloth, $4 50; leather, $5 50 ; half Russia, $6. {Just Ready.) 

Few works on this subject have met withas great 
a demand at this one appears to have. To judge 
by the frequency with which its author's views are 
quoted, and its statements referred to in obstetrical 
literature, one wo.uld judge that there are few phy- 
sicians dev)ting much attention to obstetrics who 
are without it. The author is evidently a man of 



ripe experience and conservative views, and in no 
branch of medicine are these more valuable than in 
this. — New Remedies, Jan. 1880. 

We gladly welcome the new edition of this excel- 
lent text-booK of midwifery. The former editions 
have been most favorably received by the profes- 
sion on both sides of the Atlantic In the prepara- 
tion of the present edition the author has made such 
alterations as the progress of obstetric id science 
seems to require, and we cannot but admire the 
ability with whicn the task has been performed. 
We consider it an admirable text-book for students 
during their attendance upon lectures, and have 
great pleasnre in recommending it. As an exponent 
of the midwifery of the present day it has no supe- 



rior in the English language. — Canada Lancet , Jan. 
1S80. 

The book is greatlyimproved, and as such will be 
welcomed by those who are trying to keep posted in 
the rapid advances which are being made in the 
study of obstetrics. — Boston Med. and burg Journ., 
Nov i7, 1879. 

To the American student the work before us must 
prove admirably adapted, complete in all its parts, 
essentially modern in its teachings and with dem- 
on-trations noted for clearness and precision, it will 
gain in favor and be recognized as a work of stand- 
ard merit. The work cannot fail to be popular, and 
is cordially recommended.— N. 0. Med. and Surg. 
Journ., March, 1SS0. 

Leishman's is certainly one of the best systematic 
workf on midwiiery It is very complete in all the 
parts essential for such a treati.-e To practitioneis 
and s;udents it is to be strongly recommended as a 
safe and reliable guide to the modern practice of 
midwifery. — Canada Med. and Surg. Journal, 
March, 1880. 



P 



ARRY [JOHN S.), M.D., 

Obstetrician to the Philadelphia Hospital, Viee-Prest. of the Obstet. Society of Philadelphia. 

EXTRA-UTERINE PREGNANCY: ITS CLINICAL HISTORY, 

DIAGNOSIS, PROGNOSIS, AND TREATMENT. In one handsome octavo volume. 
Cloth, $2 50. (Lately Issued.) 

JJODGE (HUGH L.), M.D., 

Emeritus Professor of Midwifery, &c, in the University of Pennsylvania, &c. 

THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Fhis- 

trated with large lithographic plates containing one hundred and fifty-nine figures from 
original photographs, and with numerous wood-cuts. In one large and beautifully printed 
quarto volume of 550 double-columned pages, strongly bound in cloth, $14. 
The work of Dr. Hodge is something more than 

a simple presentation of his particular views in the 

department of Obstetrics; it is something more 

than an >rdinary treatise on midwifery; it is, in fact, 

a cyclopaedia of midwifery. He has aimed to em- 



oody in a tingle volume the whole science and art of 
Obstetrics. In elaborate text is combined with ac- 
curate and varied pictorial illustrations so that no 
fact or principle is left unstated or unexplained. 
— Am Med. Times, 3ept. 3, 1864. 



*** Specimens of the plates and letter-press will be forwarded to any address, free by mail 
on receipt of six cents in postage stamps. ' 



VT1MSON (LEWIS A.), A. 31., M.D 

*3 Surgeon to the Presbyterian Hospital. 

A MANUAI 

royal 



NUAL OF OPERATIVE SURGERY. In one very handsome 

12mo. volume of about 500pages, with 332 illustrations ; cloth, $2 50. (Just Issued ) 
The work before us is a well printed, profusely performing them. The work is handsomely illus- 
illustrated manual of over four hundred and seventy | trated, ami the de-criptions are clear and well drawn. 



pages. The novice, by a perusal of the work, will 
gain a good idea of the general domain of operative 
surgery, while the practical surgeon has presented 
to him within a very concise and intelligible form 
the latest and most approved selections of operative 
procedure. The precision ar d conciseness with which 
the different operations are described enable the 
author to compress an immense amount of practical 
information in a very small compass— N. Y. Medical 
Record, Aug. 3, 1878. 

This volume is devoted entirely to operative sur- 
gery, and is intended to familiarize the student with 
the details of operations and the different modes of 



It is a clever and useful volume; every student 
should possess one. The preparation of this work 
does away with the necessity of poodering over 
larger works on surgery for descriptions of opera- 
tion.-, as it presents in a nut-shell just whatis wanted 
by the surgeon without an elaborate search to find 
it.— Md. Med Journal, Aug. 1878. 

The author's conciseness and the repleteness of 
the work with valuable illustrations entitle it to be 
classed with the text-books for students of operative 
surgery, and as one of reference to the practitioner. 
—Cincinnati Lancet and Ciinic, July 27, 187S. 



SKEY'* OPERATIVE SURGERY. In 1 T ol. 8vo. 
cl., of 650 pages ; withabout lOOwood-cuts. $3 25 

COOPER'S LECTURES ON THE PRINCIPLES AND 

Practice or Surgery. Inl vol. 8vo. cl'h, 750p. $2. 

GIBSON'S INSTITUTES AND PRACTICE OP SUR- 
GERY. Eighth edit'n, improved and altered. With 
thirty-four plates. In two handsome octavo vol- 
umes, about 1000 pp.. leather, raised bands. $6 50. 

THE PRINCIPLES AND PRACTICE OF SURGERY. 

By Wtlliam Pirrie,F.R S.E., Profes'r of Surgery 

the University of Aberdeen. Edited by Jobn 



3eill, M.D., Professor of Surgery in thePenna 
MedicalCollege.Surg'nto the Pennsylvania Hos- 
pital, &c. In one very handsome octavo vol of 
780 pages, with 316 illustrations, cloth, $3 75.' 
MILLER'S PRLNC1PLESOF SURGERY. Fourth Ame- 
rican, from the Third Edinburgh Edition. I n one 
large 8vo. vol. of 700 pages, with 340 illustration-: 
cloth, $3 75. ""' 

MILLER'S PRACTICE OF SURGERY. Fourth Ame 
rican, from the last Edinburgh Edition Revised bv 
the American editor. In onelarge 8vo. vol. of nearly 
"00 pages, with 364 illustrations: cloth, $3 75 



26 



Henry C. Lea's Son & Co.'s Publications — (Surgery). 



6yROSS {SAMUEL D.), M.D., 
' Professor of Surgery in the Jefferson Medical College of Philadelphia. 

SYSTEM OF SURGERY: Pathological, Diagnostic, Therapeutic, 

and Operative. Illustrated by upwards of Fourteen Hundred Engravings. Fifth edition 
carefully revised, and improved. In two large and beautifully printed imperial octpvo vol- 
umes of about 2300 pp., strongly bound in leather, with raised bands, $15; half Russia, 
raised bands, $16. 
The continued favor, shown by the exhaustion of successive large editions of this great work, 
proves that it has successfully supplied a want felt by American practitioners and students. In 
the present revision no pains have been spared by the author to bring it in every respect fully 
up to the day. To effect this a large part of the work has been rewritten, and the whole en- 
arged by nearly one-fourth, notwithstanding which the price has been kept at its former very 
moderate rate. By the use of a close, though very legible type, an unusually large amount of 
matter is jondensed in its pages, the two volumes containing as much as four or five ordinary 
octavos. This, combined with the most careful mechanical execution, and its very durable bind 
ing renders, it one of the cheapest works accessible to the profession. Every subject properly 
belonging to the iomain of surgery is treated in detail, so that the student who possesses this 
work may be said to have in it a surgical library. 



We have now brought our task to a conclusion, and 
have seldom read a work with the practical value ot 
which we have been moreimpressed. Every chapter is 
so concisely put together, that the busy practitioner, 
when in difficulty, can at once find the information he 
requires. His work, on the contrary, is cosmopolitan, 
the surgery of the world being fully represented in it. 
The work, in fact, is so historically unprejudiced, and 
so eminently practical, that it is almost a false compli- 
ment to say that we believe it to be destined to occupy 
a foremost place as a work of reference, while a system 
of surgery like the present system of surgery is the 
practice of surgeons. The printingand binding of the 
work is unexceptionable; indeed.it contrasts, in the 
latter respect, remarkably with English medical an«t 
surgical cloth-bound publications, which are generally 
so wretchedly stitched as to require re- binding before 
they are anytime in use. — Dub. Journ. of Med. Sci.. 
March, 1874. 

Dr. Gross's Surgery, a great work, has become still 
greater, both in size and merit, in its most recent form. 
The difference in actual number of pages is not more 
than 130, but. the size of the page having been in- 
creased to what we believe is technically termed ••ele- 
phant." there has been room for considerable additions, 
which, together with the alterations, are improve- 
ments. — Lond. Lancet., Nov. 16, 1872. 

It combines, as perfectly as possible, the qualities of 
a text-book and work of reference. We think this last 



edition of Gross's "Surgery," will confirm his title of 
•' Primus inter Pares." It is learned, scbolar-like, me- 
thodical, precise, and exhaustive. We scarcely think 
any living man could write so complete and faultless a 
treatise, or comprehend more solid, instructive matter 
in the given number of pages. The labor must have 
been immense, and the work gives evidence of great 
powers of mind, and the highest order of intellectual 
discipline and methodical disposition, and arrangement 
of acquired knowledge and personal experience. — N.Y. 
Med. Journ., Feb 1873. 

As a whole, we regard the work as the representative 
"System of Surgery" in the English language. — St. 
Louis Medical and Surg. Journ., Oct. 1872, 

The two magnificent volumes before us afford a very 
complete view of the surgical knowledge of the day. 
Some years ago we had the pleasure of presenting the 
first edition of Gross's Surgery to the profession as a 
work of unrivalled excellence; and now we have the 
result of years of experience, labor. and study, all con- 
densed upon the great work before us. And to students 
or practitioners desirous of enriching their library with 
a treasure of reference, we can simply commend the 
purchase of these two volumes of immense research — 
Cincinnati Lancetand Observer, Sept. 1872. 

A complete system of surgery — not a mere text-book 
of operations, but a scientific account of surgical theory 
and practice in all its departments. — Brit, and For, 
M»d Chir. Rev., Jan. 1873. 



Z?F THE SAME AUTHOR. 

A PRACTICAL TREATISE ON THE DISEASES, INJURIES, 

and Malformations of the Urinary Bladder, the Prostate Grland, and the Urethra. Third 
Edition, thoroughly Revised and Condensed, by Samuel W. Gross, M.D., Surgeon to 
the Philadelphia Hospital. In one handsome octavo volume of 574 pages, with 170 illus- 
trations: cloth, $4 50. (Just Issued.) 



For reference and general information, the physician 
or surgeon can find no work that meets their necessities 
more thoroughly than this, a revised edition of an ex- 
cellent treatise, and no medical library should be with- 
out it. Replete with handsome illustrations and good 
ideas, it has the unusual advantage of being easily 
comprehended, by the reasonableand practical mannei 
in which the various subjects are systematized and 
arranaed We heartily recommend it to the profession 
as a valuableadditiontotheimportantliteratureofdis- 



- Atlanta Med. Journ., Oct. 



eases of the urinary organs. 
1876. 

It is with pleasure we now again take up this old 
work in a decidedly new dress. Indeed, it must be re- 
garded as a new book in very many of its parts. The 
chapters on "Diseases of the Bladder," "Prostate 
Body," and "Lithotomy," are splendid specimens of 
lescriptive writing; while the chapter on ••Stricture' 
is one of the most concise and clear that we have ever 
read. — New York Med. Journ., Nov. 1876. 



T>Y THE SAME AUTHOR. 

A PRACTICAL TREATISE ON FOREIGN BODIES IN 

AIR-PASSAGES. In 1 vol. 8vo., with illustrations, pp. 468, cloth, $2 75. 



THE 



D 



RUITT {ROBERT), M.R.C.S., #c. 

THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. 

A new and revised American, from the eighth enlarged and improved London edition Illus - 
trated with four hundred and thirty -two wood engravings. In one very handsome octa\o 
volume, of nearly 700 large and closely printed pages, cloth, $4 00 ; leather, $5 00. 



All that the surgical student or practitioner could 
desire. — Dublin Quarterly Journal. 

It is a most admirable book. We do not know 
when we have examined one with more pleasure. — 
Boston Med. and Surg. Journal. 

In Mr. Drnitt'e book, though containingonly some 
seven hundred pages, both the principles and the 



practice of surgery are created, and so clearly and 
perspicuously, as toelucidateeveryimportanttopit . 
We have examined thebook mostthoroughly, and 
can *ay that thissuccessis well merited. His book 
moreover, possesses the inestimable advantages of 
having the subjects perfectly well arranged and 
classified and of being written in a style at once 
clear and succinct. — Am. Journal of Med. Sciences. 



Henry C. Lea's Son & Co.'s Publications — (Surgery). 



27 



SHHURST (JOHN, Jr.), M.D., 

Prof, of Clinical Surgery, Univ of Pa., Surgeon to the Episcopal Hospital, Philadelphia. 

THE PRINCIPLES AND PRACTICE OF SURGERY. Second 

edition, enlarged and revised. In one very large and handsome octavo volume of over 
1000 pages, with 542 illustrations. Cloth, $6 j leather, $7; half Russia, $7.50. {Just 
Ready.) 



Conscientiousness and thoroughness are two very 
marked traits of character in the author of this 
book. Out of these traits largely has grown the 
success of his mental fruit in the past, and the pre- 
sent offer seems in no wise an exception to what has 
gone before. The general arrangement of the vol- 
ume is the sameasin the first edition, hut everypart 
has been carefully revised, and much new master 
added.— Phila. Med. Times, Feb. 1, 1S79. 

We have previously spoken of Dr. Ashhurst's 
work in terms of praise We wish to reiterate those 
terras here, and to add that no more satisfactory 
representation of modern surgery has yet fallen 
from the press. In point of judicial fairness, of 
power of condensation, of accuracy and conciseness 
of expression and thoroughly good English, Prof. 
Ashhurst has no superior among the surgical writers 
in America. — Am. Practitioner, Jan. 1S79. 

The attempt to embrace iu a volume of 1000 pages 
the whole field of surgery, general and special, 
would be a hopeless ta>k unless through the most 
tireless industry in collating and arranging, and 
the wisest judgment in condensing and excluding. 
These facilities have been abundantly employed by 
the author, and he has given us a most excellent 
treatise, brought up by the revision for the second 
edition to the latest date. Of course this book is not 
designed for specialists, but as a course of general 
surgical knowledge and for general practitioners, 
and as a text-book for students it is not surpassed 
by any that has yet appeared, whether of home or 
foreign authorship. — N. Carolina Med. Journal, 
Jan. 1879. 



[ Ashhur3t'a Surgery is too well known in this 
' country to require special commendation from us. 
I This, its second edition, enlarged and thoroughly 
I revised, brings it nearer our idea of a model text- 
j book than any recently published treatise. Though 
numerous additions have been made, the size of the 
j work is not materially increased The main trouble 
\ of text books of modern times is that they are too 
i cumbersome. The student needs a book which will 
| furnish him the most information in the shortest 
time In every respect this work of Ashhurst is 
' the model text-book- full, comprehensive and com- 
| pact. — Nashville Jour, of Med. and Surg., Jan. '79. 
The favorable reception of the first edition is a 
I guarantee of the popularity of this < dition, which is 
! fresh from the editor's hands with many enlarge- 
| ments and improvements. The author of this work 
is deservedly popular as an editor and writer, and 
his contributions to the literature of surgery have 
gained for him wide reputation. The volume now 
offered the profession will add new laurels to those 
already won by previous contributions. We can 
only add that the work is well arrange d, filled with 
practical matter, and contains in brief and clear 
language all that is necessary to be learned by the 
student of surgery whilst in attendance upon lec- 
tures, or the general practitioner in hi* daily routine 
practice. — Md. Med. Journal, Jan. 1879. 

The fact that this work has reached a second edi- 
tion so very soon after the publication of the first 
one, speaks more highly of its merits than anything 
we might say in the way of commendation. It 
seems to have immediately gained the favor of stu- 
dents and physicians. — Cincin. Med. News, Jan. '79. 



T>RYANT (THOMAS), F.R.C.S., 

M-* Surgeon to Guy's Hospital. 

THE PRACTICE OF SURGERY. Second American, from the Sec- 
ond and Revised English Edition. With Six Hundred and Seventy two Engravings on 
Wood. In one large and very handsome imperial octavo volume of over 1000 large and 
closely printed pages. Cloth, $6 ; leather, $7 (Just Ready.) 
This work has enjoyed the advantage of two thorough revisions at the hand of the author since 
the appearance of the first American edition, resulting in a very notable enlargement of size and 
improvement of matter. In England this has led to the division of the work into two volumes, 
which are here comprised in one, the size being increased to a large imperial octavo, printed on 
a condensed but clear type The series of illustrations has undergone a like revision, and will 
be found correspondingly improved. 

The marked success of the work on both sides of the Atlantic shows that the author has suc- 
ceeded in the effort to give to student and practitioner a sou id and trustworthy guide in the 
practice of Surgery ; while the simultaneous appearance of the present edition in England and 
in this country affords to the American reader the benefit of the most recent advances made 
abroad in surgical science. 

There are so many text-books of surgery, so many , 
written by skilled and distinguished hands, that to ob 
tain the honor of a third edition in England is no light 
praise. Mr. Bryant merits this, by clearness of style, 
and good judgment in selecting the operations he re- | 
commends, in his new editions he goes carefully over 
the <_ld grounds, in light of later research. On these 
and many allied points, Mr. Bryant is a calm and un- 
partisan observer, and his book throughout has the 
great merit of maintaining the true scientific, judicial 
tone of mind.— Med. and Surg. Reporter, March 22, 
1879. 



The work before us is the American reprint of the 
last London edition, and has the advantage over the 
latter in being of more convenient size, and in being 
compressed into one volume. The author has rewrit- 
ten the greater part of the work, and has succeeded. 
in the amount of new matter added, in making it mark- 
edly distinctive from previous edi ions. A few extra 
pages have been added, and also a few new illustrations 
introduced. The publishers have presented the work 
in a creditable style. As a concise and practical manual 
of British surgery it is perhaps without an equal, and 
will doubtless always be a favorite text-book with the 
student and practitioner. — N. 1\ Med. Record, March 
22, 1879. 



Another edition of this manual having been called 
for, the author has availed himself of the opportunity 
to make no few alterations in the substance as well 
as in the arrangement of the work, and, with a view 
to its improvement, has recast the materials and re- 
vised the whole. We ourselves are of the opinion 

that there is no better work on surgery extant. 

Cincinnati Med. News, Match, 1879 

Bryant's Surgery has been favorably received from 
the first, and evidently grows in the esteem of the 
profession with each succeeding edition. In glanc- 
ing over che volume before us wefiud proof in almost 
every chapter of the thorough revision which the 
work has undergone, many parts having been cut 
out and replaced by matter entirely fresh.— N. Y. 
Med. -loum., April, 1879. 

Welcome as the new edition is, and as much as it 
is entitled to commendation, yet its appearance at 
this time is, in a cercain sense, a matter of regret, as 
it will be in competition with another work, lately 
issued from the snme press. But, the difficult task 
of forming a judgment as to the relative merits of 
Bryant and Ashhurst we will not attempt, but pre- 
dict that, considering the high excellence of both, 
many others will likewise be xorced to hesitate long 
in ina-king choice between them.— Cincinnati Lan- 
cet and Clinic, March 22, 1879. 



28 



Henry C. Lea's Son & Co.'s Publications — (Surgery), 



JjJRICRSEN {JOHN E.), 

Professor of Surgery in University College, London, etc. 

THE SCIENCE AND ART OF SURGERY; being a Treatise on Sur- 

gical Injuries, Diseases, and Operations. Carefully revised by the author from the 
Seventh and enlarged English Edition. Illustrated by eight hundred and sixty two en- 
gravings on wood. In two large and beautiful octavo volumes of nearly 2000 pages : 
cloth, $8 50 ; leather, $10 50 ; half Russia, $11 50. {Now Ready.) 

In revising this standard work the author has spared no pains to render it worthy of a continu- 
ance of the very marked favor which it has so long enjoyed, by bringing it thoroughly on a 
level with the advance in the science and art of surgery made since the appearance of the 
last edition. To accomplish this has required the addition of about two hundred pages of text, 
while the illustrations have undergone a marked improvement. A hundred and fifty additional 
wood-cuts have been inserted, while about fifty other new ones have been substituted for figures 
which were not deemed satisfactory. In its enlarged and improved form it is therefore pre- 
sented with the confident anticipation that it will maintain its position in the front rank of 
text-books for the student, and of works of reference for the practitioner, while its exceedingly 
moderate price places it within the reach of all. 



The seventh edition is before the world as the last 
word of surgical science. There may be monographs 
which excel it upon certain points, but as a con- 
spectus upon surgical principles and practice it is 
unrivalled. It will well reward practitioners to 
read it, for it Las been a peculiar province of Mr. 
Erichsen to demonstrate the absolute interdepend- 
ence of medical and surgical science We need 
scarcely add, in conclusion, that we heartily com- 
mend the work to students that they may be 
grounded in a sound faith, and to practitioners as 
an invaluable guide at the bedside.— Am Practi- 
tioner, April, 1878. 

It is no idle compliment to say that this is the Best 
edition Mr. Erichsen has ever produced of his well- 
known book. Besides inheriting the virtues of its 
predecessors, it possesses excellences quite its own. 
Having stated that Mr. Erichsen ha,s incorporated 
into this edition every recent improvement in the 
science and art of surgery, it would be a supereroga- 
tion to give a detailed criticism. In short, we un- 
hesitatingly aver that we know of no other single 
work where the student and practitioner can gain at 
once soclear an insight into the principles of surgery, 
and so complete a knowledge of the exigencies of 
surgical practice.— London Lancet, Feb. 14, 1878. 

For the past twenty years Erichsen's Surgery has 
maintained its place as the leading text-book, not only 
in this country, but in Great Britain. That it is able 
to hold its ground, is abundantly proven by the tho- 
roughness with which the present edition has been 
revised, and by the large amount of valuable mate- 
rial thai has been added. Aside from this, one hun- 
dred and tifty new illustrations have been inserted, 
including quite a number of microscopical appear- 
ances of pathological processes. So marked is this 
change for the better, that the work almost appears 
as an entirely new one. —Med. Record, Feb. 23,1878. 



Of the many treatises on Surgery which it has been 
our task to study, or our pleasure to read, there is none 
which in all points has satisfied us so well as the classic 
treatise of Erichsen. His polished, clear style, his free- 
dom from prejudice and hobbies, his unsurpassed grasp 
of his subject, and vast clinical experience, qualify him 
admirably to write a model text-book. "When we wish, 
at the least cost of time, to learn the most of a topic in 
surgery, we turn, by preference, to his work. It is a 
pleasure, therefore, to see that the appreciation of it is 
general, and has led to theappearance of another edi- 
tion. — Med. and Surg. Reporter, Feb. 2, 1878. 

Notwithstanding the increase in size, we observe that 
much old matter has been omitted. The entire work 
has been thoroughly written up, and not merely amend- 
ed by a few extra chapters A great improvement has 
been made in the illustrations. One hundred and fifty 
new ones have been added, and many of the old ones 
have been redrawn. The author highly appreciates the 
favor with which his work has been received by Ameri- 
can surgeons, and has endeavored to render his latest 
edition more than ever worthy of their approval. That 
he has succeeded admirably, must, we think, be the 
general opinion. We heartily recommend the book to 
both student and practitioner. — N. Y.Med. Journal,, 
Feb. 1878. 

Erichsen has stood so prominently forward for 
years as a writer on Surgery, that his reputation is 
world wide, and his name is as familiar to the med- 
ical student as to the accomplished and experienced 
surgeon. The work is not a reprint of former edi 
tions, but has in many places been entirely rewrit- 
ten. Recent improvements in surgery have not es- 
caped his notice, various new operations have been 
thoroughly analyzed, and their merits thoroughly 
discussed. One hundred and fifty new wood-cuts 
add to the value of this work. — N. O. Med. and Surg. 
Journal, March, 1878. 



TJOLMES {TIMOTHY), M.D., 

-*-JL Surgeon to St. George's Hospital, London. 

SURGERY, ITS PRINCIPLES AND PRACTICE. In one hand- 
some octavo volume of nearly 1000 pages, with 411 illustrations. Cloth, $6; leather, $7 : 
half Russia, $7 50. {Just Issued.) 

its force and distinctness.— N. Y. Med. Record, April 
14, 1876. 

It will be found a most excellent epitome of sur- 
gery by the general practitioner who has not the 
time togiveattention to more minute and extended 
works and to the medical student. In fact, we know 
of no one we can more cordially recommend. The 
author has succeeded well in giving a plain and 
practical account of each surgical injury and dis- 
ease, and of the treatment which is most com- 
monly advisable. It will no doubt become a popu- 
lar workin the profession, and especially as a text- 
book. — Cincinnati Med. News, April, 1876. 



This is a work which has been lookedfor on both 
sides of the Atlantic with much interest. Mr. Holmes 
is a surgeon of large and varied experience, and one 
of the best known, and perhaps the most brilliant 
writer upon surgical subjects in England. It is a 
book for students — and an admirable one — and for 
the busy general practitioner. It will give a student 
all the knowledge needed to pass a rigid examina- 
tion. The book fairly justifiesthe high expectations 
that were formed of it. Its style is clear and forcible, 
even brilliant at times, and the conciseness needed 
to bring it wit hi nits properlimitshas not impaired 



ASHTON ON THE DISEASES, INJURIES, and MAL- 
FORMATIONS OF THE RECTUM AND ANUS: 
with remarks on Habitual Constipation. Second 
American, from the fourth and enlarged London 
Edition. With illustrations. In one 8vo. vol. ot 
287 pages, cloth, $3 26. 



SARGENT ON BANDAGING AND OTHER OPERA- 
TIONS OF MINOR SURGERY. New edition, with 
an additional chapter on Military Surgery. One 
12mo. vol. ol383pag98 withl84 wood-cuts. Cloth, 
$175. 



Henry C. Lea's Son & Co.'s Publications — {Ophthalmology). 



29 



H 



AMILTON [FRANK H.), M.D., 

Professor of Fractures and Dislocations, Ac, in Sellevue Hosp. Med. College, New York. 

A PRACTICAL TREATISE ON FRACTURES AND DISLOCA- 
TIONS. Fifth edition, revised and improved. In one large and handsome octavo volume 
of nearly 800 pages, with 344 illustrations. Cloth, $5 75 ; leather, $6 75. (Lately Is stied.) 



TXTELLS [J.SOELBERG), 

' ' Professor of Ophthalmology in King's College Hospital, &c. 

A TREATISE ON DISEASES OF THE EYE. 



Third American, 



from the Third London Edition. Thoroughly revised, with copious additions, by Chas. 
S. Bull, M D. , Surgeon and Pathologist to the New York Eye and Ear Infirmary. Illus- 
trated with about 250 engravings on wood, and six colored plates. Together with selec- 
tions from the Test-types of Jaeger and Snellen. In one large and very handsome 
octavo volume of 900 pages. (In Press.) 
The long- continued illness of the author, with its fatal termination, has kept this work for 
some time out of print, and has deprived it of the advantage of the revision which he sought 
to give it during the last years of hi; life. This edition has therefore been placed under the 
editorial supervision of Dr. Bull, who has labored earnestly to introduce in it all the advances 
which observation and experience have acquired for the theory and practice of ophthalmology 
since the appearance of the last revision. To accomplish this, considerable additions have been 
required, and the work is now presented in the confidence that it will fully deserve a continu- 
ance of the very marked favor with which it has hitherto been greeted as a complete, but con- 
cise, exposition of the principles and facts of its important department of medical science. 

The additions made in the previous American editions by Dr. Hays have been retained, 
including the very full series of illustrations and the test-types of Jaeger and Snellen. 

l^ETTLESHIP {EDWARD), F.R.C.S., 

-*-' Ophthalmic Surg, and Led. on Ophth. Surg, at St. Thomas' 1 Hospital, London. 

MANUAL OF OPHTHALMIC MEDICINE. In one royal 12mo. 

volume of over 350 pages, with 89 illustrations. Cloth, $2. (Just Ready.) 



The book is written in a careful and logical man- 
ner, and though extremely concise, we have failed 
to notice any evidence of ambiguity. It is rendered 
more compact and homogeneous by frequent refer- 
ences, by page number, to other portions of the 
work ; repetitions are thus avoided, and we have 
been surprised to find how much information our 
author has succeeded in conveying in so small a 
space. A careful study of the book will well repay 
tbe general practitioner, even though it should 
serve only as a monitor. It is particularly useful 
in the latter regard, as the subject of treatment is I 



presented in a thoroughly conservative manner. — 
N. Y. Mad. Record, March 6, 1880. 

The author has succeeded in touching upon about 
all the points, operations, diseases of the eye in 
relation to general diseases, and has prepared a very 
acceptable book. — Cincinnati Lancet and Clinic, 
Feb. 7, 1880. 



It is multum in parvo, containing all the leading 
points to be remembered in the pathology, descrip- 
tion, and treatment of diseases of the eye. It will 
be found especially valuable in preparing for exam- 
inations. Practitioners will find it convenient as a 
woi-k of reference, when they wish to refresh their i 



memories in respect to the features of some affec- 
tions. — Cincinnati Med. News, Jan 1880. 

The author 's to be congratulated upon the very 
successful manner in which he has accomplished his 
task; he has succeeded in being concise without 
sacrificing clearness and, including the whole 
ground covered by more voluminous text-books, 
has given an excellent re'st'me' of all the practical 
information they contain. We do not hesitate to 
pronounce Mr JSlettleship's book the best manual on 
ophthalmic surgery for the use of students and 
' busy practitioners" with which we are acquain- 



ted. — Am. Jour. Med. Sciences, April, 1880. 

A careful examination has convinced us that it is 
the best work of its class that has come to our notice. 
While all matter is condensed to the utmost, there 
aie few points that are obscured thereby, and all 
are rendered really attractive totheaverage student. 
We can only hope that every medical student shall 
be compelled to master the entire volnme ere re- 
ceiving his degree. General practitioners who take 
care of eye cases would do well to refresh their 
memories by its careful study. — Detroit Lancet, 
April, 18S0. 



a 



AR7ER {R. BRUDENELL), F.R.C.S., 

Ophthalmic Surgeon to St. George' s Hospital, etc. 

A PRACTICAL TREATISE ON DISEASES OF THE EYE. Edit- 

ed, with test-types and Additions, by John Green, M.D. (of St. Louis, Mo.). In one 
handsome octavo volume of about 500 pages, and 124 illustrations. Cloth, $3 75. (Just 
Issued.) 

It is with great pleasure that we can endorse the work [ chapter is devoted to a discussion of the usesandselec- 
as a most valuable contribution to practical ophthal- tion of spectacles, and is admirably compact, plain, and 
mology. Mr. Carter d ever deviates from the end he has I useful, especially the paragraphs on the treatment of 
in view, and presents the subjectin a clear and concise j presbyopia and myopia. In conclusion, our thanks are 
manner, easy of comprehension, and hence the more due the author for many useful hints in the great suh- 
valuable. We would especially commend, however, as jject of ophthalmic surgery and therapeutics, afield 
worthy of high praise, the manner in which the thera- I whereof late years we glean but a few grains of sound 
peutics of disease of the eve is elaborated, for here the wheat from a mass of chaff — New York Medical Record, 
author is particularly clear and practical, where other | Oct. 23, 1875. 
writers are unfortunately too often deficient. The final I 



OROWNE [EDGAR A.), 

•*-* Surgeon to the Liverpool Eye and Ear Infirmary, and to the Dispensary for Skin Diseases. 

HOW TO USE THE OPHTHALMOSCOPE. Being Elementary In- 

structionsin Ophthalmoscopy, arranged for the Use of Students. With thirty-five illustra- 
tions. In one small volume royal 12mo. of 120 pages : cloth, $1. (Now Ready.) 



LAURENCE'S HANDS' BOOK OF OPHTHALMIC 
SURGERY, for the use of Practitioners. Second 
edition, revised and enlarged With numerous 
illustrations. In one very handsome octavo vol- 
ume cloth, $2 75. 



LAWSON'S INJURIES TO THE EYE, ORBIT, 
AND EYELIDS: tbeir Immediate and Remote 
Eifects. With about one hundred illustrations. 
In one very handsome octavo volume, cloth 
*3 50. 



30 Henry C. Lea's Son & Co.'s Publications — (Med. Jurisprudence), 



J^URNETT (CHARLES H.), M.A , M.D., 

■*-* Aural Surg to the Presb. Mosp., Surgeon-in-charge ofthelnfir for Bis. of the Ear, Phila. 

THE EAR, ITS ANATOMY, PHYSIOLOGY, AND DISEASES. 

A Practical Treatise for the Use of Medical Students and Practitioners. In one hand- 
some octavo volume of 61 6 pages, with eighty-seven illustrations : cloth, $4 50 ; leather, 
$5 50 ; half Russia, $6 00. {Now Ready.) 
Recent progress in the investigation of the structures of the ear, and advances made in the 
modes of treating its diseases, wouldseem to render desirable a new work in which all the re- 
sources of the most advanced science should be placed a+ the disposal of the practitioner. This 
it has been the aim of Dr. Burnett to accomplish, and the advantages which he has enjoyed in 
the special study of the subject are a guarantee that the result of his labors will prove of service 
to the profession at large, as well as to the specialist in this department. 



Foremost among the numerous recent contribu- 
tions to aural literatur* will be ranked this work 
of Dr. Burnett. It is impossible to do justice to 
this volume of over 600 pages in a necessarily brief 
notice. It must suffice to add that the boot is pro- 
fusely and accurately illustrated, the references are 
conscientiously acknowledged, while the result has 
been to produce a treatise which will henceforth 
rank with the classic writings of Wilde and Von 
Trolsch.— The Lond. Practitioner, May, 1879 



On account of the great advances which have been 
made of late years in otology, and of the increased 
interest manifested in it, the medical profession will 
welcome this new work, which presents clearly and 
concisely its present aspect whilst clearly indi- 
cating the direction in which further researches can 
be most profitably carried on. Dr. Burn tt from his 
own matured experience, and availing himself of 
the observations and discoveries of others, has pro- 
duced a work, which as a text-book, stands facile 
princeps in our language. We had marked several 
pa-sages as well worthy of quotation and the atten- 
tion of the general practitioner, but their number and j given to th 
the space at our command forbid. Perhaps it is bet- I Med. Journ 
ter, as the book ought to be in the hands of every | 



medical student, and its study will well repay the 
busy practitioner in the pleasuie he will derive from 
the agreeable style in which many otherwise dry 
aud mostly unknown subjects are treated. To the 
specialist the work is of the highest value, and bis 
sense of gratitude to Dr. Burned will we hope, be 
proportionate to the amount of benefit lie can obtain 
from the careful study of the book, and a constant 
reference to its trustworthy pages.— Edinbw gh 
Med. Jour., Aug. 1878. 

The book is designed especially for the use of stu- 
dents and general practitioners, and places at their 
disposal much valuable material. Such a book as 
the presentone, we think, haslongbeen needed, and 
we may congratulate the author on his success in 
filling the gap. Both student and practitioner can 
study the work with a great deal of benefit. It is 
profusely and beautifully illustrated.— N. Y. Hos^ 
pital Gazette, Oct 15, 1877. 

Dr. Burnett is to becommended for having written 
the best book on the subject in the English language, 
and especially for the care and attention he has 

scientific side of the subject. — N. Y. 

Dec. 1877. 



*AYLOR (ALFRED S.),M.D., 

Lecturer on Med. Jurisp. and Chemistry in Guy's Hospital. 

POISONS IN RELATION TO MEDICAL JURISPRUDENCE AND 

MEDICINE. Third American, from the Third and Revised English Edition. In one 
large octavo volume of 850 pages ; cloth, $5 50 ; leather, $6 50. (Jtist Issued.) 



The present is based upon the two previous edi- 
tions; "but the complete re vision rendered necessary 
by time has converted it into a new work." This 
statement from the preface contains all that it is de- 
sired to know in reference to the new edition. The 
works of this author are already in the library of 
every physician who is liable to be called upon for 
medico-legal testimony (and what neis not?), so that 
all that is required to be known about the present 
book is that the author has kept it abreast with the 
times. What makes it now, as always, especially 
valuable to the practitioner is its conciseness ana 
practical character, only those poisonous substances 



being described which give rise to legal investiga- 
tions.— The Clinic, Nov. 6, 1875. 

Dr. Taylor hat brought to bear on the compilation 
of this volume, stores of learning, experience, and 
practical acquaiutancewithn is subject, probably far 
beyond what any other living authority on toxicol- 
ogy could have amassed or utilized. He has fully 
sustained his reputation by the consummate skill 
and legal acumen he has displayed in the arrange- 
ment of the subject-matter, and the result is a work 
on Poisons which will beindispensable to every stu- 
dent or practitioner in lawand medicine. — The Dub- 
lin Journ. of Med Sci., Oct. 1875. 



T> T THE SAME AUTHOR. 

MEDICAL JURISPRUDENCE. 

by John J. Reese, M.D., Prcf. of Med. 
octavo volume of nearly 900 pages. Olo 

To the members of the legal and medical profes- 
sion, it is unnecessary to say anything commenda- 
tory of Taylor's Medical Jurisprudence. We might 
as well undertake to speak of the nerit of Chitty's 
Pleadings.— Chicago Legal News, Oct. 16, 1873. 

It is beyond question the most attractive as well 
as most reliable manual of medical jurisprudence 
published in the English language.— Am. Journal 
of Syphilography, Oct. 1873. 

It is altogether superfluous for us to offer anything 
in behalf of a work on medical j urisprudence by an 
author who is almost universally esteemed to be the 



Seventh American Edition. Edited 

Jurisp. in the Univ. of Penn. In one large 
th, $5 00; leather, $6 00. (Lately Issued.) 
best authority on this specialty in our language. On 
thispoint, however, we will say thai weconsiderDr. 
Taylor to be the safest medico-legal authority to fol- 
low, in general, with which we areacquaintedin any 
language. — Va. Clin. Record, Nov. 1873. 

This last edition of the Manual is probably the best 
of all, as it contains more material and is v, orked up 
to the latest views of the author as expressed in the 
last edition of the Principles. Dr. Reese, the editor 
of the Manual, has done everything to make his 
workacceptable to his medical countrymen. — N. Y. 
Med. Record, Jan. 15, 1874. 



nr THE SAME AUTHOR. 

THE PRINCIPLES AND PRACTICE OF MEDICAL JURISPRU- 

DENCE. Second Edition, Revised, with numerous Illustrations. In two large octavo 

volumes, cloth, $10 00; leather, $12 00 
This great work is now recognized in England as the fullest and mostauthoritativetreatise on 
very department of its important subject. In laying it, in its improved form, before the Amer- 
ican profession, the publishers trust that it will assume the same position in this country. 



Henry C. Lea's Son & Co.'s Publications — (Miscellaneous). 31 



ROBERTS {WILLIAM), M.D., 

-*•*' Lecturer on Medicine in the Manchester School of Medicine, etc. 

A PRACTICAL TREATISE ON URINARY AND RENAL DIS- 
EASES, including Urinary Deposits. Illustrated by numerous cases and engravings. Third 
American, from the ThirdRevised and Enlarged London Edition. In one largt and 
handsome octavo volume of over 600 pages. Cloth, $4. (Just Ready.) 

THOMPSON (SIR HENRY), 

-*■ Surgeon and Professor of Clinical Surgery to University College Hospital . 

LECTURES ON DISEASES OF THE URINARY ORGANS. With 

illustrations on wood. Second American from the Third English Edition. In one neat 
octavo volume. Cloth, $2 25. {Just Issued.) 



B 



Y THE SAME AUTHOR. 

ON THE PATHOLOGY AND TREATMENT OF STRICTURE OF 

THE URETHKA AND URINARY FISTULA. With plates and wood-cuts. From the 
third and revised English edition. In one very handsome octavo volume, cloth, $3 50. 
( Lately Published.) 

r*UKE [DANIEL HACK), AID , 

Joint author of ' ' The Manual of Psychological Medicine,' 1 '' &c. 

ILLUSTRATIONS OF THE INFLUENCE OF THE MIND UPON 

THE BODY IN HEALTH AND DISEASE. Designed to illustrate the Action of the 
Imagination. In one handsome octavo volume of 416 pages, cloth, $3 25. (Lately Issued .) 



J>LANDFORD (O. FIELDING), M.D., F.R.G.P., 

J-J Lecturer on Psychological Medicine at the School of St. George's Hospital, &c. 

INSANITY AND ITS TREATMENT: Lectures on the Treatment, 

Medical and Legal, of Insane Patients. With a Summary of the Laws in force in the 
United States on the Confinement of the Insane. By Isaac Rav, M. D. In one very 
handsome octavo volume of 471 pages; cloth, $3 25. 

actually seen in practice and the appropriate treat- 
ment for them, we tind in Dr. Blaudford's work a 
considerable advance over previous writings on tie 
subject. His pictures of the various forms of meDtal 
disease are so clear and good that no reader can fail 
to be struck with their superiority to those given in 
ordinary manuals in the English language or (so far 
as our own reading extends )i n any other. — London 
Practitioner, Feb. 1871. 



It satisfies a want which must have been sorely 
felt by the busy general practitioners of this country. 
t takes the form of a manual of clinical description 
of the various forms of insanity, with a description 
of the mode of examining persons suspected of in- 
sanity. We call particular attention to this feature 
of the book, as givingit a unique value to the gene- 
-al practitioner. If we pass from theoretical conside- 
rations to descriptions of the varieties of insanity as 



EA (HENRY C). 
SUPERSTITION AND FORCE: ESSAYS .ON THE WAGER OF 

LAW, THE WAGER OF BATTLE, THE ORDEAL, AND TORTURE. Third Revised 
and Enlarged Edition. In one handsome royal 12mo. volume of 552 pages. Cloth, 
$2 50. (Just Ready.) 

more accurate than either of the preceding, but, 
from the thorough elaboration is more like a har- 
monious concert and less like a batch of studies. — 
The Nation, Aug. 1, 1878. 

Many will be tempted to say that this, like the 
••DeclineandFall,''isone of the uncriticizable books 
Its facts are innumerable, its deductions simple and 
inevitable, and its chevaux-dt-frise of references 
bristling and dense enough to make the keenest, 
stoutest, and best equipped assailant think twice 
before advancing. Nor is there anything contro- 
versial in it to provoke assault. The author is no 
polemic. Though he obviously feels and thinks 
strongly, he succeeds in attaining impartiality. 
Whetler looked on as a picture or a mirror, a work 
such as this has a lasting value.— Lippin cotV s 
Magazine, Oct. 1878. 



This valuable work is in reality a history of civi- 
lization as interpreted by the progress of jurispru- 
dence. ... In "Superstition and Force" we have 
a philosophic survey of the long period intervening 
between primitive barbarity and civilized enlight- 
enment. There is not a chapter in the work that 
should not be most carefully studied, and however 
well versed the reader may be in the science of 
jurisprudence, he will find much in Mr. Lea's vol- 
ume of which he was previously ignorant. The 
book is a valuable addition to the literature of 
social science. — Westminster Review, Jan. 1880. 

The appearance of a new edition of Mr. Henry C. 
Lea's "Superstition and Force" is a sign that our 
highest scholarship is not without honor in its na- 
ti re country. Mr. Lea has met every fresh demand 
for his work with a careful revision of it, and the 
present eaition is not only fuller and, if possible, 



J^Y THE SAME AUTHOR. (Lately Published.) 

STUDIES IN CHURCH HISTORY— THE RISE OF THE TEM- 
PORAL POWER— BENEFIT OF CLERGY— EXCOMMUNICATION. In one large 
royal 12mo. volume of 516 pp.; cloth, $2 75. 
The story was never told more calmly or with uasapeculiarimportancefortheEnglishstudent.and 



greater learning or wiser thought. We doubt, indeed, 
if any other study of this field can be compared with 
this for clearness, accuracy, and power. — Chicago 
Examiner, Dec. 1870. 

Mr. Lea's latest work, " Studiesin Church History," 
filly sustains the promise of the first. It deals with 
three subjects— the Temporal Power, Benefit of 
Clergy, and Excommunication, the record of which 



is a chapter on Ancient Law likely to be regarded as 
final. We can hardly pass from our mention of such 
works as these — with which that on "Sacerdotal 
Celibacv" should be included — without noting the 
literary phenomenon that the head of one of the first 
American houses is also the writer of some of its most 
original books. — London Athenceum, Jan. 7, 1871. 



32 



Henry C. Lea's Son & Co.'s Publications. 



INDEX TO CATALOGUE. 



stry 



American Journal of the Medical Sciences 

Allen's Anatomy 

Anatomical Atlas, by Smith and Horner 

Ashton on the Rectum and Anus 

Attfleld's Chemistry . 

Ashwell on Diseases of Females 

*lshhurst's Surgery . 

Browne on Ophthalmoscope . 

Browne on the Throat . 

*Burnett on the Ear 

*3arnes on Diseases of Women . 

Barnes' Midwifery 

Bellamy's Surgical Anatomy 

Bryant s Practice of Surgery 

Bloxam's Chemistry . 

Blandford on Insanity . 

Basham on Renal Diseases . 

Bartholow on Electricity 

ftariow's Practice ol Medicine . 

Bowman's (John E.)Practical Chemi 

*Bristowe's Practice 

*Buinstead on Venereal 

Bamstead and Cullerier's Atlasof Venereal 

^Carpenter's Human Physiology 

Carpenter on the Use and Abuse of Alcohol 

*Cornil and Ranvier 

Carter on the Eye . 

Cleland's Dissector 

Classen's Chemistry 

Clowes' Chemistry 

Century of American Medicine 

Chad wick on Diseases of Women 

Charcot on the Nervous System 

Chambers on Diet and Regimen 

Christison and Griffith's Dispensatory 

Churchill's System of Midwifery 

Churchill on Puerperal Fever . 

Condie on Diseases of Children . 

Cooper's (B. B.) Lectures on Surgery 

Cullerier's Atlas of Venereal Diseases 

Cyclopasdia of Practical Medicine 

Duncan on Diseases of Women . 

*Dalton's Human Physiology 

Davis's Clinical Lectures 

Dewees on Diseases of Females . 

Druitt's ModernSurgery 

*Dunglison's Medical Dictionary 

Ellis's Demonstrations in Anatomy, 

*Erichsen's System of Surgery . 

*Emmet on Diseases of Women . 

Farquharson's Therapeutics 

Foster's Physiology 

Fenwick's Diagnosis .... 
Finlayson's Clinical Diagnosis . 
Flint on Respiratory Organs 
Flint on the Heart .... 
Flint's Practice of Medicine. 
Flint's Essays ; 

^Flint's Clinical Medicine . 

Flint on Phthisis 

Flint on Percussion .... 
Fothergill's Handbook ofTreatment . 
Fothergill's Antagonism of Therapeutic Age 
Fownes's Elementary Chemistry 
Fox on Diseases of the Skin 
Fuller on the Lungs. &c. . 
Green's Pathology and Morbid Anatomy 
Greene's Medical Chemistry 

Gibson's Surgery 

Gluge's PathoxOgical Histology, by Leidy 

*Gray's Anatomy^ 

Galloway's Analysis .... 

Griffith's (R. E.) Universal Formulary 

Gross on Urinary Organs . 

Gross on Foreign Bodies in Air-Passages 

* } ross'* Sy*Lem of Surgery 

Habershon on the Abdomen . 

Hamilton on Dislocations and Fractures 

Bartshorne's Essentials of Medicine . 

Hartshorne's Conspectus of the Medical Science 

Hartshorne's Anatomy and Physiology 

Hamilton on Nervous Diseases . 

Henth's Practical Anatomy 

Hoblyn's Medical Dictionary . 



PAGE 

. 1 

. 7 
. 7 
. 28 
. 10 
. 21 
. 27 
. 29 
. 19 
. 30 
. 22 
, 24 
. 7 

27 
. 11 
. 31 

19 
, 18 

14 
9 

16 

20 
, 20 
, 8 
. 12 
, 14 

29 
7 
9 

11 
5 



Hodge on Women 

Hodge's Obstetrics . . . 

Holland's Medical Notes and Reflections . 
*Holmes's Surgery ..... 
Holden's Landmarks .... 

Horner's Anatomy and Histology . 

Hudson on Fever 

Hill on Venereal Diseases .... 
Hillier's Handbook of Skin Diseases 
Jones (C. Handheld) on Nervous Disorders 
Knapp's Chemical Technology . 
Lea's Superstition and Force . 

Lea's Studiesin Church History 

Lee on Syphilis 

*Leishman's Midwifery .... 

La Roche on Yellow Fever. 

La Roche on Pneumonia, &c. 

Laurence and Moon's Ophthalmic Surgery 

Lawson on the Eye .... 

Lehmann's Physiological Chemistry, 2 vols. 

Lehmann's Chemical Physiology 

Ludlow's Manual of Examinations . 

Lyons on Fever ..... 

Medical News and Abstract 

Morris on Skin Diseases 

Meigs on Puerperal Fever . 

Miller's Practice of Surgery 

Miller's Principles of Surgery . 

Montgomery on Pregnancy 

Nettleship's Ophthalmic Medicine 

Neill and Smith's Compendium ol Med.Sci* 

Obstetrical Journal 

Parry on Extra-Uterine Pregnaney 

Pavy on Digestion 

*Parrish's Practical Pharmacy . 

Pirrie's System of Surgery . 

*Playfair's Midwifery .... 

Quain and Sharpey's Anatomy, by Leidy 

^Reynolds' System of Medicine . 

Richardson's Preventive Medicine 

Roberts on Urinary Diseases 

Ramsbotham on Parturition 

Remsen's Principles of Chemistry . 

Rigby's Midwifery .... 

Rodwell's Dictionary of Science . 

Stimson's Operative Surgery 

Swayne's Obstetrie Aphorisms . . • 

Seiler on the Throat .... 

Sargent's Minor Surgery 

Sharpey and Quain's Anatomy, by Leidy 

Skey's Operative Surgery . 

Slade on Diphtheria . . . 

Schafer's Histology . . . . 

*Smith (J. L.) on Children . 

Smith (H. H.) and Horner's Anatomical Atl( 

Smith (Edward) on Consumption 

Smith on Wasting Diseases in Children 

*Still£'s Therapeutics .... 

*Stille & Maisch's Dispensatory . 

Sturges on Clinical Medicine 

Stokes on Fever 

Tanner's Manual of Clinical Medicine 

Tanner on Pregnancy .... 

Taylor's Medical Jurisprudence 

Taylor's Principles and Practice of Med Jurisp 

Taylor on Poisons ... 

Tuke on the Influence of the Mind . 

*Thomas on Diseases of Females 

Thompson on Urinary Organs 

Thompson on Stricture . 

Todd on Acute Diseases 

Woodbury's Practice .... 

Walshe on the Heart .... 

Watson's Practice of Physic 

Walls on the Eye 

West on Diseases of Females 

West on Diseases of Children . 

Weston Nervous Disorders of Childre] 

Williams on Consumption . 

Wilson's Human Anatomy . 

Wilson's Handbook of Cutaneous Medicin< 

Wiihler's Organic Chemistry 

Winckel on Childbed .... 



21 

26 
14 
28 
6 
7 
19 
20 
19 
IS 
11 
31 
31 
20 
25 
14 
19 
29 



19 
2 
IS 
*1 
25 
25 
21 
29 
.6 
24 
25 
14 
11 
25 
24 
7 
17 
16 
31 
23 
9 
21 
4 
25 
21 
19 
28 
7 
26 
19 
7 

21 

7 

19 

21 
12 
13 

15 

14 
5 

23 

30 

30 

30 

31 

22 

31 

31 

14 

16 

19 

15 

29 

20 

20 

20 

19 
7 

19 
9 

23 



Books marked * are also bound in half Russia. 



HENRY C. LEA'S SON & CO.— Philadelphia. 



